In my experience, two of the most challenging underwriting topics for advisors to understand are liver disease and kidney disease. The two have nothing to do with each other so I believe the reasons are a lack of understanding of the functions of these organs and the lab-test alphabet soup that accompanies adverse underwriting decisions based on impairments of these organs. In the following article, I’ll describe the functions of the liver and kidneys; I’ll describe how diseases and disorders affect each organ; and I’ll explain how to interpret the lab results that to the lay person appear to be just random letters on a page.
The liver is located in the right upper quadrant of the abdomen and is the largest solid organ in the human body…approximately the size of a football. This is of course dependent on body size and sex. The average weight of the liver is three pounds. The liver is one of the most diverse organs in terms of its numerous functions, the most important of which include the production of bile which helps to break down fats in the small intestine during digestion, the production of certain proteins for blood plasma, and the production of cholesterol and special proteins to help carry fats through the body. This is only a sample of what the liver does with some experts believing there may be as many as 500 functions that it performs. Because the liver is so multi-functional, screening for past, current, and potentially future liver disease is a critical part of analyzing a life insurance risk.
One of the most well known and most common liver diseases is Hepatitis (‘hepato’ is the Greek word for liver and ‘itis’ is the Greek word for disease, especially an inflammatory disease). Therefore hepat-itis literally means inflammation of the liver which is exactly what Hepatitis is. There are five primary types of Hepatitis: A, B, C, D, and E. The two types that insurance companies care about most are Hepatitis B which has no cure and Hepatitis C which can indeed now be cured. Many insurance companies test for Hepatitis B and C on every client, but some only test at certain ages and death benefits.
Insurance companies determine the ratings for individuals who have a history of Hepatitis B and C based on several factors, most of which are blood tests. The first tool underwriters use is the liver enzyme panel.
Liver Enzymes (also called Liver Function Tests or LFT’s) are one of the most confusing subjects for many advisors to understand and to explain to their clients. The reason is that a) many times there is no way to determine the cause of the elevations, and, b) LFTs are only screening tests and not diagnostic tests which is also difficult to explain to clients. Sometimes insurance companies don’t actually know why mortality is affected by a particular lab elevation and no definitive cause is determined, but mortality studies do show that life expectancy is affected by these elevations.
The four liver enzyme tests that life insurance companies look at are the GGT (Gamma Glutamyl Transpeptidase), the AST (Aspartate Aminotransferase), the ALT (Alanine Aminotransferase), and the ALP (Alkaline Phosphatase).
The term ‘Liver Function Test’ is technically inaccurate even though it is used almost universally. What these tests actually show are potential damage to the liver…when these enzyme assays are found in higher concentrations in the blood, it can be a sign of damage to liver cells called hepatocytes. However, this isn’t the entire story. Because these enzymes are also found in other organs throughout the body (skeletal and cardiac muscle, bone and intestine), elevations can also be a sign of other disease processes. Below are a few examples:
- AST elevation without alteration of ALT suggests the cause of the elevation is not related to the liver.
- AST elevations in excess of ALT elevations are suggestive of alcohol abuse.
- ALP elevation without a change in GGT suggests a bone origin.
- Elevation of GGT with elevations of ALT and/or AST, where GGT is the predominant elevation can be a sign of another liver condition called Cholestasis.
- GGT elevation with an increased MCV and/or HDL cholesterol suggests alcohol abuse.
As the above bullet points suggest, liver enzyme tests are not diagnostic…they are only screening tests. So additional testing by the proposed insured’s personal physician would have to be performed to actually make a diagnosis. However, subject to how elevated the liver enzymes are, and assuming there’s no history of Hepatitis or other liver disorders in the proposed insured’s past, an actual diagnosis isn’t always or even usually necessary to obtain an offer of life insurance.
The next step the underwriter takes when a proposed insured has a known history of Hepatitis B or C, assuming the liver enzymes are normal, is to request additional tests to be run on the existing blood sample. Details of these additional lab tests are beyond the scope of this article, but these test results can also usually be found in the insured’s medical records which will always be requested by the underwriter. Finally, if a liver biopsy has been performed, it will also have to be obtained and reviewed by the underwriter or one of the medical directors at the insurance company. Once the underwriter has all of this information they can determine how much damage has been done to the liver, how much viral load is currently in the blood, if the insured should be approved or declined and, if approved, at what rate class.
I won’t get into the types of treatment or rates of success, but many people can indeed now be cured of Hepatitis C. A very important point to remember is that many people who have had successful treatment have had the disease for several years, many times without knowing it. Therefore, even after being cured and the virus is no longer detectable in the bloodstream, there are many instances where the virus did substantial damage to the liver prior to treatment so an offer of life insurance either still isn’t possible or the rating will be extremely high. But for those individuals who had mild disease, little damage to the liver, and successful treatment, excellent offers are usually possible.
The other medical condition that’s more confusing than it really should be, especially with regards to the lab results, is kidney disease.
The kidneys lay behind the liver on either side of the spinal column. The average size of each kidney is approximately the size of a large fist and it is estimated that the kidneys can hold up to 22 percent of the body’s blood volume at a time. The primary function of the kidneys is to remove waste from the blood, but they also regulate the ph of bodily fluids, regulate blood pressure, and help ensure homeostasis in the body among other things.
The kidneys are basically a very intricate and complex filtration system. When blood enters the kidneys (technically when it enters the inner part of the kidney called the nephron), waste and other material are separated from the blood. The material that the body needs is then re-absorbed into the bloodstream and the waste material is expelled through the ureters and into the bladder. And the newly filtered blood returns to the rest of the body through the renal veins.
I won’t go into the several types of kidney disease in this article but will just use the generic term “kidney disease” when referring to the breakdown of the filtration process noted above. Initial screening tests for kidney disease are done in two ways—blood tests and urine tests. Blood tests determine if waste isn’t being filtered from the blood efficiently. This is done by measuring the amount of this waste left in the bloodstream. Urine tests determine if substances that should be re-absorbed after being filtered out aren’t being re-absorbed as they should be. This is done by measuring the amount of these substances in the urine.
The most common test to diagnose kidney disease is a blood test, or more accurately three blood tests…the Serum Creatinine, the BUN (Blood Urea Nitrogen), and the GFR (Glomerular filtration rate). These three tests are run on every blood panel done for life insurance and these three tests are run virtually every time an MD checks a patient’s blood. I’m going to focus on the Serum Creatinine and GFR, as the BUN plays a smaller role in life insurance underwriting.
Serum Creatinine is a waste product derived from the breakdown of muscle tissue. If, as is stated above, an individual has kidney disease, the kidneys don’t filter out the Serum Creatinine as they should, and it builds up in the bloodstream. By testing the level of Creatinine on the insured’s blood panel, the insurance company can detect possible kidney disease.
The Glomerular Filtration Rate or GFR is a derivative of the Serum Creatinine test that takes into account the proposed insured’s age, race and gender as these factors can determine what a normal Creatinine level is for each individual. It is easiest to think of the GFR as a percentage of kidney function. A GFR result of 100 can be thought of as 100 percent kidney function/efficiency. Therefore, the Creatinine and GFR have an inverse relationship. The higher the Creatinine level (the amount of waste left in the blood), the lower the GFR (an expression of how well the kidneys are functioning).
The other screening tool that underwriters use in determining kidney function are urine results, specifically testing for glucose and protein in the urine. When blood enters the kidney, several substances are filtrated out of the blood. The good substances that the body needs to survive like glucose and protein are re-absorbed into the bloodstream and travel back to the other organs that need them to function properly. But when an individual has kidney disease, this re-absorption is hampered, and glucose and protein are expelled with waste material through the urine. By testing for glucose and protein in the urine, underwriters can detect possible kidney disease.
Stages of Kidney Disease
One of the most confusing aspects of underwriting kidney disease is the classification system of chronic kidney disease or CKD. Below is the classification system used by most physicians.
- GFR >90: Stage 1 CKD
- GFR 60-89: Stage 2 CKD
- GFR 30-59: Stage 3 CKD
- GFR 15-29: Stage 4 CKD
- GFR <15: Stage 5 CKD
As you can see, the GFR test is the basic unit of measurement when determining the stage of kidney disease. But medical records will often reflect a stage that isn’t backed-up by the lab results in the medical records or on the insurance exam. The stage noted in the medical records is many times noted to be worse than what the lab results actually reflect, so if you have a client who is rated or declined based solely on what the medical records indicate the stage of kidney disease is, always verify with the underwriter if the lab results do indeed reflect this. Many times they don’t and this may save a case from being rated or declined inappropriately.
Kidney Disease Treatment
There unfortunately isn’t any true treatment for kidney disease in most cases. Treating the contributing factors such as blood pressure, obesity, and diabetes can help stabilize the condition, but this is really all that can be done. Note that stability is the key to getting the best underwriting offer possible. For example, someone with a GFR in the 50s (Stage 3 CKD) that has been stable for several years will many times get a better underwriting offer than someone with a current GFR in the 60s (Stage 2 CKD) but whose GFR has been dropping by five points every year for the last five years.
How liver disease and kidney disease are underwritten seem to be two of the more difficult topics for advisors and their clients to understand. But when you understand the lab results and what they mean and how to interpret them, it becomes easier to work with the underwriter for a potentially better rate class or at worst to help explain to your client why the offer that’s being made is what it is. Being the well-rounded expert in the eyes of your client will only help solidify the relationship you’ve worked so hard to create.