Background This study aimed to determine the costs and distribution of healthcare spending of patients with chronic kidney disease (CKD) at stages 3 and 4 and on dialysis both at the individual and population level in Germany. Methods The study took the perspective of the German statutory health insurance (SHI) system and analyzed claims data on 3,687,015 insurees from the year 2014. To extrapolate costs to the whole SHI population, a literature search on the prevalence of CKD was conducted. Results Average costs per person per year in an age-and gender-matched control group of the normal population were €2,876 (95% confidence interval [CI], €2,798 to €2,955) and �2.8-fold higher in CKD patients (€8,030 [95% CI, €7,848 to €8,212] at CKD stage 3, €9,760 [95% CI, €9,266 to €10,255] at CKD stage 4, and €44,374 [95% CI, €43,608 to €45,139] on dialysis). At CKD stages 3 and 4 the major cost driver was hospitalizations, contributing to more than 50% of total expenditures. Among dialysis patients, hospitalizations and dialysis-treatment costs contributed to 23% and 53% of total healthcare spending, respectively. At CKD stages 3 and 4, patients with the highest 20% of healthcare spending showed a considerable increase in per-patient costs over the reference population, while the bottom 80% of patients generated only moderately higher per-patient costs (p < 0.001). Comparing total CKD costs to total SHI expenditures yields that 10.2% of SHI expenditures was driven by patients at CKD stages 3 and 4 and 1.6% by dialysis patients. Conclusions Healthcare spending of patients with CKD at stages 3 and 4 and on dialysis is concentrated among a small number of high-need patients. As hospitalizations and dialysis treatment are key drivers of total expenditures, strategies that lead to a reduction in hospitalizations, delay
