Residual Functional Capacity Assessment for Kidney Damage
What Is RFC?
When your pneumoconiosis is not severe enough to meet or equal a listing at Step 3 of the Sequential Evaluation Process, the Social Security Administration will need to determine your residual functional capacity (RFC) to decide whether you are disabled at Step 4 and Step 5 of the Sequential Evaluation Process.RFC is a claimant’s ability to perform work-related activities. In other words, it is what you can still do despite your limitations. An RFC for physical impairments is expressed in terms of whether the Social Security Administration believes you can do heavy, medium, light, or sedentary work in spite of your impairments. The lower your RFC, the less the Social Security Administration believes you can do.
Assessing Impairment Caused by Kidney Damage
There is no straightforward way that RFC can be correlated with specific abnormalities of serum creatinine or creatinine clearance. A person with a serum creatinine of 2 or 3 mg/dl (mg%) may not have a significant impairment from a standpoint of physical function. However, as the creatinine begins to exceed 4 mg/dl, the complications of bone disease, anemia, and hypertension become more likely. Complications become more likely the longer chronic renal disease has been present. Certainly, claimants who are close to meeting the listing requirements of part C would qualify for a sedentary RFC. For example, if the serum creatinine is 4 mg/dl and the hematocrit is 31 or 32%, a RFC for a maximum of sedentary work could be justified. Autonomic neuropathy in which there is an orthostatic drop in blood pressure with changes in body position could limit bending and lifting. The easiest way to determine RFC in cases like this is to search for controlling variables—such as the hematocrit as mentioned above—that are related to the listing and set some kind of functional ceiling. Find the medical variable that sets the lowest ceiling, so that it is known that the RFC cannot exceed a certain level. Then consider whether that lowest ceiling can be lowered further by the interaction with other medical variables. For example, malnutrition is a common part of chronic kidney disease. If a claimant had a persistent serum creatinine of 4 mg/dl, persistent hemocrits of 32%, and a BMI of less than 18.0, then a finding of equivalence could easily be justified from what started out as a RFC analysis (see Meeting Social Security Administration Listing 6.02C for Kidney Damage).
After downwardly adjusting the lowest ceiling RFC by consideration of variables referenced by relevant listings, further consideration can be given to other factors not mentioned by the listing such as whether there is difficulty in thinking (cognitive dysfunction) which would require mental evaluation. As uremic toxins rise as a result of renal failure, it is predictable that cognitive changes are going to take place—particularly if there is already a co-morbid organic brain dysfunction. Even if there is just decreased alertness, that could affect a claimant’s ability to work around hazardous machinery or perform abstract tasks like accounting. The list of abnormalities that can be associated with chronic renal disease should always be considered (see Abnormalities Associated with Chronic Renal Failure).
Claimants with polycystic kidney disease must avoid abdominal and back trauma that would be acceptable for normal people. They also have a painfully enlarged liver with cysts. Of course, no one has any medical studies on the matter of how much such claimant should lift and bend, or what kind of force to the abdomen a transplanted kidney can survive, but common sense would dictate avoidance of working conditions that would cause significant jarring or bumps to the abdominal area. The claimant should also be asked if they have any abdominal discomfort bending. These are not the kinds of things that a treating physician usually thinks about. The claimant’s help in describing symptoms under certain kinds of physical forces during activities of daily living can be helpful. Finally, there may well be other impairments besides kidney disease, such as lupus, scleroderma, heart disease or many other possible disorders that could modify overall severity.
As for claimants post-transplantation, they may be persistent abnormalities associated with chronic renal failure that have not been fully reversed with a new organ so they must be carefully evaluated before any consideration of termination of benefits, looking at all of the variables brought up by part C (hematocrit, weight, etc.). Also, the immunosuppressive drugs, as previously discussed, convey additional risks for impairment. If a healthy claimant received a new kidney soon after developing renal failure and recovered fully without any complication or symptoms, it is conceivable that they could have no significant functional limitation. However, this is not usually the case if one looks closely.
Go back to About Kidney Damage and Disability.