Posetta Mayo sits in her sunroom, lamenting the roses that need tending outside her window while looking at the surgically created clump under the skin of her left arm.
The roses have to wait, and so does she. Mayo's name just got added to the long list of people in Tennessee needing a kidney transplant. The mass on her arm is a fistula, an access point for dialysis. She had worried about a stroke after being diagnosed with high blood pressure, never realizing the threat to her kidneys.
"A simple blood test at random found this," Mayo said. "At that point, my kidneys were working at 19 percent. I'm checked every few months. Now, we're down to 13 percent."
The Dickson County woman battled weight and high blood pressure for years. Now, at age 64, she's about to start dialysis. She's lost her appetite, suddenly dropping pounds and feeling fatigued. But the worst part of it is she knows time is not on her side.
New cases of people diagnosed with kidney failure have more than doubled in Tennessee, increasing from 1,078 in 1990 to 2,574 by 2009, according to federal figures. The supply of kidneys isn't keeping pace with the people who need transplants, and taxpayers are having to pick up the tab.
Researchers attribute the leap to rising rates of diabetes and high blood pressure - conditions that slowly destroy the kidneys without warning signs and often go hand in hand with being overweight. Among diabetics in this state, the incidence rate tripled over the same period of time.
More recent figures provided by BlueCross BlueShield of Tennessee indicate the problem is not going away. The insurer had 11,032 people with kidney failure on its rolls last year, compared with 8,967 the prior year.
But the largest expense is borne by Medicare, which spent $23.3 billion on patients with kidney failure - 8 percent of its total costs - according to the 2011 United States Renal Data System annual report.
The numbers may be alarming, but they should not be a surprise, given the obesity epidemic, said Dr. David Reagan, chief medical officer for the state Health Department.
"Two-thirds of our adult population and one-third of our children in this state are overweight or obese," Reagan said. "It's an extraordinarily widespread problem."
Gov. Bill Haslam's Health and Wellness Task Force has made the state's obesity epidemic its primary focus and is convening community leaders to devise an action plan. The link between being overweight and developing kidney disease is one of the many health consequences of obesity, but Reagan said people do not understand the magnitude of this particular condition.
Influx of patients
Every day, more new patients walk into TriStar Centennial Medical Center, one of four Nashville hospitals that has a kidney transplant program.
"We are seeing this huge influx of patients coming in with kidney disease now with the aging population and the baby boomers," said Dr. Ranjan Chanda, a nephrologist.
While older people account for the largest portion, more people in their 20s, 30s and 40s also are ending up on dialysis from the metabolic stress of carrying around excess weight. Nationwide, newly diagnosed cases of kidney failure rose 29.5 percent among people ages 20 to 44 since 1990.
Dr. Chike Nzerue, a nephrologist and professor at Meharry Medical College who treats patients at Nashville General Hospital, sees the consequences of undiagnosed hypertension. Access to health care and a lack of transportation contribute to health disparities. Blacks are more prone to kidney disease and often face obstacles getting it diagnosed and treated.
"A 28-year-old African-American gentleman born and raised in Nashville - the first time I am seeing him, I am putting him on a dialysis machine," Nzerue said. "That is a failure of all the educational institutions in the health care setting in the whole city. Someone should not go on dialysis the first time they are seeing a doctor and they are 28 years old."
The man's high blood pressure had gone undiagnosed and untreated for too long.
While diabetes is the leading cause of kidney failure nationally, in this region the primary culprit is hypertension. Thirty-three percent of the people on the kidney waiting list in the greater Tennessee area are there because of a history of high blood pressure. Twenty-six percent are there because of diabetes.
"This is the salt belt between Tennessee, Arkansas, Georgia, South Carolina - you know, where you have all the good Southern cooking - you also have the high incidence of hypertension, kidney failure and strokes," Nzerue said.
While cutting back on sodium intake can help prevent and control high blood pressure, kidney disease requires other actions. The key to avoiding dialysis is identifying the disease at an early stage, said Dr. Joseph Vassalotti, the National Kidney Foundation's chief medical officer.
Early stages of kidney disease affect nearly one in 10 people in the U.S.
Dr. Adriana Hung, a nephrologist with the Veterans Affairs hospital in Nashville, said blood and urine tests can detect kidney disease but are often not performed at doctors' offices. People with high blood pressure or diabetes should ask their doctor to check their kidneys, she said.
Barriers to care
Prediabetes is often the first leg of the road to kidney failure.
"There is this gray zone ... where you're not diabetic and you're not normal," Hung said. "You are prediabetic. People need to understand when you are there you have to start doing your lifestyle modifications."
Race also is a risk factor for kidney disease. African-Americans, Hispanics, Pacific Islanders and American Indians have higher rates than whites.
"African-Americans are usually about three times more likely to develop kidney failure than Caucasian people," Vassalotti said.
Barriers to health care, such as going without insurance or being without transportation, keep poor people from staying in treatment. Nzerue has seen it happen.
"I had a patient in June who came to me," Nzerue said. "He was 31 years old. His blood pressure was 240 over 150. His kidneys were half shut down. I made a contract with him. I said, 'You come to the clinic every week and I'll see you and I'll get medicines for you for free.' "
The patient did not return until two weeks ago, when his kidneys were shutting down.
"Doc, I didn't have a car," he told Nzerue. "I didn't have the money to come to see you."
Preventive therapy for this patient - medicine that would have cost about $4 a month - has been replaced with dialysis three times a week at a yearly cost of about $50,000, Nzerue said.
'I believe in miracles'
Mayo, who is scheduled to start dialysis this month, can't stop worrying.
When she drives down the interstate and sees the count of state traffic fatalities, she wonders how many were organ donors. She half-jokingly asks people she barely knows to give her one of their kidneys.
"You know," she said, "I believe in miracles."
Things do work out sometimes.
In July 2011, when Darryl Reece told The Tennessean he did not pray for a kidney because he didn't want someone to die for him to get a transplant, a woman from his Nashville church saw the article and offered to be a living donor. She was a match.
In May, when Adam Luster of Donelson died from a brain injury, his family decided to donate his organs. They designated friends for his kidneys. Both turned out to be matches.
In Tennessee, 949 people died from kidney disease in 2009, the last year for which figures are available. Not enough kidneys are donated to meet the rising list of people who need them.