Disability Evaluation Under Social Security
(Blue Book- October 2008)
6.00 Genitourinary Impairments - Adult
A. What impairments do these listings cover?
- We use these listings to evaluate genitourinary impairments resulting from chronic renal disease.
- We use the criteria in 6.02 to evaluate renal dysfunction due to any chronic renal disease, such as chronic glomerulonephritis, hypertensive renal vascular disease, diabetic nephropathy, chronic obstructive uropathy, and hereditary nephropathies.
- We use the criteria in 6.06 to evaluate nephrotic syndrome due to glomerular disease.
B. What do we mean by the following terms in these listings?
- Anasarca is generalized massive edema (swelling).
- Creatinine is a normal product of muscle metabolism.
- Creatinine clearance test is a test for renal function based on the rate at which creatinine is excreted by the kidney.
- Diastolic hypertension is elevated diastolic blood pressure.
- Fluid overload syndrome associated with renal disease occurs when there is excessive sodium and water retention in the body that cannot be adequately removed by the diseased kidneys. Symptoms and signs of vascular congestion may include fatigue, shortness of breath, hypertension, congestive heart failure, accumulation of fluid in the abdomen (ascites) or chest (pleural effusions), and peripheral edema.
- Glomerular disease can be classified into two broad categories, nephrotic and nephritic. Nephrotic conditions are associated with increased urinary protein excretion and nephritic conditions are associated with inflammation of the internal structures of the kidneys.
- Hemodialysis, or dialysis, is the removal of toxic metabolic byproducts from the blood by diffusion in an artificial kidney machine.
- Motor neuropathy is neuropathy or polyneuropathy involving only the motor nerves.
- Nephrotic syndrome is a general name for a group of diseases involving defective kidney glomeruli, characterized by heavy proteinuria, hypoalbuminemia, hyperlipidemia, and varying degrees of edema.
- Neuropathy is a problem in peripheral nerve function (that is, in any part of the nervous system except the brain and spinal cord) that causes pain, numbness, tingling, and muscle weakness in various parts of the body.
- Osteitis fibrosa is fibrous degeneration with weakening and deformity of bones.
- Osteomalacia is a softening of the bones.
- Osteoporosis is a thinning of the bones with reduction in bone mass resulting from the depletion of calcium and bone protein.
- Pathologic fractures are fractures resulting from weakening of the bone structure by pathologic processes, such as osteomalacia and osteoporosis.
- Peritoneal dialysis is a method of hemodialysis in which the dialyzing solution is introduced into and removed from the peritoneal cavity either continuously or intermittently..
- Proteinuria is excess protein in the urine.
- Renal means pertaining to the kidney.
- Renal osteodystrophy refers to a variety of bone disorders usually caused by chronic kidney failure
- Sensory neuropathy is neuropathy or polyneuropathy that involves only the sensory nerves.
- Serum albumin is a major plasma protein that is responsible for much of the plasma colloidal osmotic pressure and serves as a transport protein.
- Serum creatinine is the amount of creatinine in the blood and is measured to evaluate kidney function.
C. What evidence do we need?
- We need a longitudinal record of your medical history that includes records of treatment, response to treatment, hospitalizations, and laboratory evidence of renal disease that indicates its progressive nature. The laboratory or clinical evidence will indicate deterioration of renal function, such as elevation of serum creatinine.
- We generally need a longitudinal clinical record covering a period of at least 3 months of observations and treatment, unless we can make a fully favorable determination or decision without it. The record should include laboratory findings, such as serum creatinine or serum albumin values, obtained on more than one examination over the 3 month period.
- When you are undergoing dialysis, we should have laboratory findings showing your renal function before you started dialysis.
- The medical evidence establishing the clinical diagnosis of nephrotic syndrome must include a description of the extent of edema, including pretibial, periorbital, or presacral edema. The medical evidence should describe any ascites, pleural effusion, or pericardial effusion. Levels of serum albumin and proteinuria must be included.
- If a renal biopsy has been performed, the evidence should include a copy of the report of the microscopic examination of the specimen. However, if we do not have a copy of the microscopic examination in the evidence, we can accept a statement from an acceptable medical source that a biopsy was performed, with a description of the results.
We consider factors such as the:
- Type of therapy.
- Response to therapy.
- Side effects of therapy.
- Effects of any post-therapeutic residuals.
- Expected duration of treatment.
E. What other things do we consider when we evaluate your chronic renal disease under specific listings?
- Chronic hemodialysis or peritoneal dialysis (6.02A). A report from an acceptable medical source describing the chronic renal disease and the need for ongoing dialysis is sufficient to satisfy the requirements in 6.02A.
- Kidney transplantation (6.02B). If you have undergone kidney transplantation, we will consider you to be disabled for 12 months following the surgery because, during the first year, there is a greater likelihood of rejection of the organ and recurrent infection. After the first year posttransplantation, we will base our continuing disability evaluation on your residual impairment(s). We will include absence of symptoms, signs, and laboratory findings indicative of kidney dysfunction in our consideration of whether medical improvement (as defined in ??404.1579(b)(1) and (c)(1), 404.1594(b)(1) and (c)(1), 416.994(b)(1)(i) and (b)(2)(i), or 416.994a, as appropriate) has occurred. We will consider the:
a. Occurrence of rejection episodes.
b. Side effects of immunosuppressants, including corticosteroids.
c. Frequency of any renal infections.
d. Presence of systemic complications such as other infections, neuropathy, or deterioration of other organ systems.
- Renal osteodystrophy (6.02C1). This condition is bone deterioration resulting from chronic renal disease. The resultant bone disease includes the impairments described in 6.02C1.
- Persistent motor or sensory neuropathy (6.02C2). The longitudinal clinical record must show that the neuropathy is a "severe" impairment as defined in ??404.1520(c) and 416.920(c) that has lasted or can be expected to last for a continuous period of at least 12 months.
- Nephrotic syndrome (6.06). The longitudinal clinical record should include a description of prescribed therapy, response to therapy, and any side effects of therapy. In order for your nephrotic syndrome to meet 6.06A or B, the medical evidence must document that you have the appropriate laboratory findings required by these listings and that your anasarca has persisted for at least 3 months despite prescribed therapy. However, we will not delay adjudication if we can make a fully favorable determination or decision based on the evidence in your case record. We may also evaluate complications of your nephrotic syndrome, such as orthostatic hypotension, recurrent infections, or venous thromboses, under the appropriate listing for the resultant impairment.
What does the term "persistent" mean in these
Persistent means that the longitudinal clinical record shows that, with few exceptions, the required finding(s) has been at, or is expected to be at, the level specified in the listing for a continuous period of at least 12 months.
G. How do we evaluate impairments that do not meet one of the genitourinary listings?
- These listings are only examples of common genitourinary impairments that we consider severe enough to prevent you from doing any gainful activity. If your severe impairment(s) does not meet the criteria of any of these listings, we must also consider whether you have an impairment(s) that satisfies the criteria of a listing in another body system.
- If you have a severe medically determinable impairment(s) that does not meet a listing, we will determine whether your impairment(s) medically equals a listing. (See ??404.1526 and 416.926.) If you have a severe impairment(s) that does not meet or medically equal the criteria of a listing, you may or may not have the residual functional capacity to engage in substantial gainful activity. Therefore, we proceed to the fourth and, if necessary, the fifth steps of the sequential evaluation process in ??404.1520 and 416.920. When we decide whether you continue to be disabled, we use the rules in ??404.1579(b)(1) and (c)(1), 404.1594(b)(1) and (c)(1), 416.994(b)(1)(i) and (b)(2)(i), or 416.994a, as appropriate.
6.02 Impairment of renal function, due to any chronic renal disease that has lasted or can be expected to last for a continuous period of at least 12 months. With:
A.Chronic hemodialysis or peritoneal dialysis (see 6.00E1).
B. Kidney transplantation. Consider under a disability for 12 months following surgery; thereafter, evaluate the residual impairment (see 6.00E2).
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; or
2. Persistent motor or sensory neuropathy (see 6.00E4); or
3. Persistent fluid overload syndrome with:
a. Diastolic hypertension greater than or equal to diastolic blood pressure of 110 mm Hg; or
b. Persistent signs of vascular congestion despite prescribed therapy (see 6.00B5); or
4. Persistent anorexia with weight loss determined by body mass index (BMI) of less than 18.0, calculated on at least two evaluations at least 30 days apart within a consecutive 6-month period (see 5.00G2).
6.06 Nephrotic syndrome, with anasarca, persisting for at least 3 months despite prescribed therapy (see 6.00E5). With:
A. Serum albumin of 3.0 g per dL (100 ml) or less and proteinuria of 3.5 g or greater per 24 hours.
B. Proteinuria of 10.0 g or greater per 24 hours.