Incidence & Prevalence of ESRD

Though we live in a world that dreams of ending that always seems about to give in something that will not acknowledge conclusion insists that we forever begin. Brendan Kennelly “Begin”

American Journal of Kidney Diseases, Vol 51, Suppl 1 (January, 2008), pp S81–S98.

S82

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Growth of the end-stage renal disease (ESRD) program is typically characterized by assessment of total patient counts at a single point in time (point prevalence), of new cases accepted for treatment (incidence), and of patients receiving kidney transplants. Disease rates are computed

based on the number of patients per million people in the general population, and are adjusted for age, gender, and race. This classic approach is used because it is often difficult to define the true at-risk population for a specific disease. This year, however, we use the CDC’s county-level estimates of diabetes in the U.S. (reported by the National Center for Health Statistics) to look at the incidence of ESRD caused by diabetes, comparing these rates in the true at-risk diabetes population to those calculated by the classic method to determine if we are making progress in slowing the rise of diabetic ESRD. In rates based on this at-risk population, the incidence of ESRD due to diabetes has been falling since the mid-1990s. This is in contrast to data reported by the USRDS, which use the general population as the at-risk group, and show that diabetic ESRD rates peaked in 2003–2004 and have since remained relatively flat. Progress appearing when the diabetic population is used as the at-risk group should thus be viewed with some caution. Growth in the number of newly diagnosed diabetic patients in the U.S. has quickened since the mid-1990s. These patients may take much longer to develop ESRD than those previously diagnosed, creating a lead-time bias which dilutes the denominator and lowers the rates of ESRD. In the last five years the USRDS has noted a continued growth in the number of treated patients, but a slowing of the incident rates. More than 106,000 new patients began therapy for ESRD in 2005 (2.0 percent more than in 2004),

while the prevalent dialysis population reached 341,000 (3.3 percent more), and the prevalent transplant population grew to more than 143,693 (5.6 percent more). Both prevalent populations have more than tripled since 1988, while the number of incident patients has grown 159 percent. Since 1999, however, incident rates have been relatively stable, ranging from 333.1 per million population that year to 347.1 in 2005. The median age of the incident population has reached 64.6. With continued growth in the baby boomer population, the disease rate for this group has begun to flatten. Rates of new ESRD due to diabetes remained fairly stable in 2005, at 152, and adjusted rates for ESRD due to glomerulonephritis have in fact been falling, from a peak of 33.1 in 1994 to 26.5 in 2005. Even after adjustments for age, gender, race, and primary cause of ESRD, rates of ESRD vary widely across the U.S. This year we present new data on ESRD in the major metropolitan statistical areas (MSAs) of the country. Among African Americans, for instance, the incidence of ESRD is greatest in the Pittsburgh, Pennsylvania MSA, while for whites (includes Hispanic whites) it is highest in the Los Angeles, California MSA. These variations may reflect different burdens of chronic kidney disease, as well as regional differences in the use of detection efforts and treatment interventions in populations at risk for kidney failure. Prevalent counts continue to rise, particularly for patients age 45–64, and the rate of prevalent ESRD rose 1.9 percent in 2005 to reach 1,569 per

Percent of patients

We also projmillion populaect that total Medicare costs tion. In absolute numbers, related to ESRD will approach $54 the fastest growth is occurring billion by 2020. In the 2000 ADR we esamong patients age 45–64; rates, however, timated an ESRD budget of $28 billion by 2010, are rising most quickly among those age 65 and and actual numbers have been ahead of these proolder. Regional variations in ESRD prevalence reflect jections. These projections are subject to changes in the differences in adjusted survival, in part related to higher payment system and in the development of prevention rates of transplantation in certain areas of the U.S. and treatment programs for CKD and ESRD. We will This year we revisit earlier projections of the ESRD revisit them in the future, comparing them to actual population, and update them to 2020. These projections data to determine the impact of changes in clinical show important similarities to the actual data. Growth practice and preventive care. of the prevalent population, As in prior years, we refor instance, is close to that By age 100 port here on patients with projected in the 2000 ADR. 80 relatively rare causes of Incident counts were overESRD. Rates for ESRD due estimated by 20 percent, 60 to AIDS, for example, have but were within 1 percent been fairly constant in the of conservative projections 40 75+ last decade. ESRD due to published in JASN in 2001 65-74 20 post-transplant (non-renal) (Xue et al.). Using SAS au<65 complications has been ristoregression models, we 0 By race ing, a finding of particular now project that the inci100 concern. dent population will grow 80 Still to be determined is to 143,000 by 2020; with the whether these data reflect full Markov model, which 60 short- or long-term trends, addresses changing demo40 as the emergence of the graphics and the prevalence Other baby boomers into a senior of diabetes in the U.S. popuAfrican American 20 White population may continue to lation, we project 150,000. contribute to the growth of We also estimate a prevalent 0 1980 1985 1990 1995 2000 2005 2010 2015 2020 the overall ESRD populapopulation nearing 800,000, tion, even with moderations and a dialysis population Projected changes in the composition of the prevalent ESRD population to 2020, by age & race in disease rates. The growth of 534,000. While actual of diabetes in both the gengrowth will depend on care eral Medicare population and among younger patients given to those with CKD, results using our current is a concern as well. Ŧ projection model show consistency between historical oJXUHcounts projected using a Markov model, using data through 2005. trends and the time-dependent Markov model.

2.1

contents

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highlights

oJXUH  In 2005 the overall adjusted incidence of ESRD again remained stable, with the rate of 347 per million population only 1 percent higher than in 2001. oJXUH  The adjusted prevalence of ESRD reached 1,569 per million population in 2005, 1.4 times higher than in 1995. Annual growth in the rate, however, has slowed, and has been 3.0 percent or lower since 2001. oJXUHVqThe USRDS projects that there will be nearly 800,000 prevalent ESRD patients receiving therapy in 2020, and that more than 150,000 new patients will begin treatment that year.

S83

incidence 300

10

200

5

100

0 -5 80

2.2

82

84

86

88

90

92

00

02

04

30 78

82

86

90

94

98

02

1,400 Fee for service Medicare + Choice

1,200 1,000 800 600 93

I

95

97

99

Incident rates, by payor incident ESRD patients

01

03

05

2.7

0-19 20-44 45-64 65-74 75+

30 20 10 0 80

2.5

Median age of incident patients, by race/ethnicity incident ESRD patients

Counts

84

88

92

96

00

Urban

60 40 20

Rural

0 80

84

88

92

96

00

04

Incident counts, by geographic location incident ESRD patients

2,000

Rates 0-19 20-44 45-64 65-74 75+ All

1,500 1,000 500 0

04

80

84

88

92

96

00

04

Incident counts & adjusted rates, by age incident ESRD patients

60

Counts Male

40 Female 20

0 80

84

88

92

96

00

04

Rate per million population

40

40

Rate per million population

50

Number of patients (in thousands)

White (2005: 67.4) African Amer. (59.1) Native Amer. (58.1) Asian (64.3) Hispanic (60.3) All (64.6)

Number of patients (in thousands)

Median age (in years)

98

80

2.3

60

2.6

96

Adjusted incident rates & annual percent change incident ESRD patients

70

2.4

94

Number of patients (in thousands)

15

0

Rate per million population

S84

400

Symbols: one-year % change

Bars: Rate per million population

INCIDENCE & PREVALENCE

450

Rates Male All

300

Female 150

0 80

84

88

92

96

00

04

Incident counts & adjusted rates, by gender incident ESRD patients

n 2005 the overall adjusted incidence of ESRD again remained stable, with the rate of 347 per million population only 1 percent higher than in 2001 (Figure 2.2). In 2005, nearly 77,000 of the new ESRD patients lived in urban areas, and 26,000 in rural settings (Figure 2.3) The overall median age of new patients has changed little since the late 1990s, and in 2005 was 64.6, with a range from 58.1 in Native Americans to 67.4 in whites (Figure 2.4). Incident rates between 2000 and 2005 have been relatively steady for most age groups, changing less than 3.0 percent (Figure 2.5). For patients age 75 and older, however, the rate has grown 10 percent, from 1,570 to 1,725 per million. Incident rates in Medicare Advantage (formerly Medicare + Choice patients) were 20 percent higher in 2005 than those found in patients enrolled in a fee-for-service program (Figure 2.6). While incident counts and rates by gender have not been changing dramatically in recent years, the gap between males

and females continues to widen (Figure 2.7). The number of males beginning ESRD therapy in 2005 was 1.2 times greater than the number of females, and their incident rate was 1.5 times higher, at 434 per million population compared to 281. By geographic region, the highest incident rates of ESRD continue to occur in the south and southwestern portions of the country—from California east to Texas—and in the Ohio Valley (Figure 2.8). Interestingly, the area of the western Dakotas and eastern Montana, with some of the highest rates in 2000, had some of the lowest rates in 2005. Racial disparities in ESRD incidence continue to be dramatic (Figure 2.9). Rates in 2005 ranged from 268 per million population among whites to 991 among African Americans, 516 among Native Americans and 355 among Asians—3.7, 1.9, and 1.3 times greater, respectively. Because the most recent edition of the Medical Evidence form, released in the spring of 2005, no longer contains categories for Mexican or non-Mexican ethnicity, we have revised

2007 USRDS Annual Data Report 2000

2005

279 + (314) 259 to <279 244 to <259 229 to <244 below 229 (215)

1,200 Rate per million population

White African American Native American Asian

60 40 20 0 80

84

88

92

96

00

Rates White African American Native Amer. Asian All

900 600 300 0

04

80

84

88

92

96

00

04

100 Counts Non-Hispanic

75 50 25

Hispanic

0 96

98

00

02

Rate per million population

Incident counts & adjusted rates, by race incident ESRD patients

2.10

2.11

Counts

600 Rates Hispanic 500 400

All

300

Non-Hispanic

200

04

96

98

00

02

04

Incident counts & adjusted rates, by Hispanic ethnicity incident ESRD patients

50

Counts Rate per million population

DOOoJXUHVincident ESRD patients. ŧ oJXUHrates adjusted for age, gender, & race. oJXUHlocation determined using ZIP code of patient residence. oJXUHrates adjusted for gender & race. oJXUH unadjusted. oJXUHrates adjusted for age & race. oJXUHby HSA; adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories. oJXUHVqrates adjusted for age & gender. oJXUHrates adjusted for age, gender, & race. ŧ For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

80

2.9 Number of patients (in thousands)

Figure 2.10 to show differences in Hispanic and non-Hispanic populations. Counts of new Hispanic ESRD patients rose to nearly 12,000 in 2005, a 63 percent growth since 1996, when the Medical Evidence form first began gathering information on ethnicity. The 2005 incident rate for Hispanic patients was 490 per million population, 1.5 times higher than that found among nonHispanics. The number of patients with diabetes as the primary cause of ESRD rose 6.6 percent between 2001 and 2005 (Figure 2.11). The incident rate of diabetic ESRD, however, has flattened since a peak in 2001, remaining at 152– 153 per million population. One-third of patients start therapy with ESRD caused by hypertension; rates for these patients have been declining slightly since 2003. The largest change in rates by diagnosis has been for those with glomerulonephritis. After reaching a high of 33 per million population in the mid-1990s, the rate fell to 26.5 by 2005, with a one-year decline of nearly 6 percent after 2004. Ŧ

Number of patients (in thousands)

Geographic variations in adjusted incident rates (per million population), by HSA incident ESRD patients

Number of patients (in thousands)

2.8

S85

372 + (408) 351 to <372 332 to <351 315 to <332 below 315 (292)

Diabetes Hypertension Glomerulonephritis Cystic kidney

40 30 20 10 0 80

84

88

92

96

00

04

160

Rates

120 80 40 0 80

84

88

Incident counts & adjusted rates, by primary diagnosis incident ESRD patients More on incident patient counts & rates: p.a, p.2–3 & p.6, Chapter Four, 8.13–14 (pediatric patients).

92

96

00

04

incident rates of ESRD based on at-risk populations Number of people (in millions)

INCIDENCE & PREVALENCE

200 150

0-44 45-64 65-74 75+

100 50 0 80

88

92

96

00

04

Counts of the general U.S. population, by age

6

12

4

6

2

0

0

-6 80

2.13

82

84

86

88

90

92

94

96

98

00

02

04

Number of patients (in thousands)

Unadjusted rates of diabetes in the U.S. population, & annual percent change

20

0-44 45-64 65-74 75+ All

15 10 5 0 80

2.14

Symbols: one-year % change

Percent of population

2.12

Percent of population

S86

84

84

88

92

96

Unadjusted rates of diabetes in the U.S. population, by age

T

00

04

24

0-44 45-64 65-74 75+

18 12 6 0 80

2.15

84

88

92

96

00

04

Incident counts of ESRD patients with diabetes as primary diagnosis

he incidence of ESRD is likely to be influenced by changing demographics in the general population. In this spread we present information on diabetes in the general population, and illustrate trends in incidence using two different methods. The National Center for Health Statistics (NCHS), of the Center for Disease Control and Prevention, reports the prevalent level of diabetes in the country using data collected through surveillance programs from state and county departments of health. Based on these data, the incidence of diabetes in the United States has risen to 5.3 percent, with the major growth occurring in those age 45 years and older (Figures 2.13–14). This at-risk population can be used to compute rates of incident ESRD due to diabetes—a method developed by the CDC and reported in the Morbidity and Mortality Weekly Review (MMWR, 2005). Fig-

2007 USRDS Annual Data Report

3,000

0-44 45-64 65-74 75+ All

800 600

2,000

400

1,000

200

80 84 88 92 96

2.16

20-44 45-64 65-74 75+ All

00 04

4,000

Denominator: CDC DM population

500

8,000

400

6,000

300

4,000

200

2,000

100

150

2,000

100

80 84 88 92 96

00 04

Male Female All

1,000

00 04

2.17

CDC diabetic population: 0-44

Adjusted incident rates of ESRD with diabetes as primary diagnosis, by race incident ESRD patients

ures 2.16–18 illustrate the differences in adjusted incident rates of ESRD caused by diabetes when these rates are calculated with either the CDC’s diabetic population or the general population as the denominator. Using the CDC diabetic data, it appears that ESRD due to diabetes has been declining since the mid-1990s. Data reported by the USRDS, in contrast, show the rate stabilizing in most populations over the last five years. It is important to consider the factors that may contribute to these differences. ESRD rates based on the general population would appear the most conservative, since the denominator at risk is the entire U.S. population; the CDC’s diabetes population is most likely to be at risk for diabetic ESRD. In this latter population, early detection of the disease may create a lead-time bias, with newly diagnosed diabetic patients taking longer to develop ESRD since their disease is identified earlier. With each method, however, the most important general finding centers on the slowing of rates of ESRD due to diabetes, which may reflect improved preventive care such as glycemic and blood pressure control and the treatment of hyperlipidemia. Ŧ oJXUHdata obtained from the CDC’s National Center for Health Statistics, at http://www.cdc.gov/nchs/about/major/dvs/popbridge/datadoc.htm. Estimates based on the April 1, 2000, resident counts of the U.S. Census Bureau. oJXUHdata from the National Diabetes Surveillance System, at http://www. cdc.gov/diabetes/statistics/prev/national/index.htm. oJXUHdata from the National Diabetes Surveillance System, at http://www.cdc.gov/diabetes/statistics/prev/national/figage.htm. oJXUHVqincident ESRD patients.

00 04

S87

60

2,000

30

1,000

15

8,000

1,000 750

4,000

500

2,000

250

0

0

65-74

2,000

7,500

1,500

5,000

1,000

2,500

500

0 10,000

0

75+

1,500

8,000

1,200

6,000

900

4,000

600

2,000

300

0

0 00

2.19

White African American Other

0

45-64

6,000

10,000

General population: 20-44

45

3,000

00 04

80 84 88 92 96

00 04

0 80 84 88 92 96

50

Adjusted incident rates of ESRD with diabetes as primary diagnosis, by gender incident ESRD patients

4,000

White Af. Amer. Other All

Denominator: general population

0 80 84 88 92 96

Denominator: general population

200

3,000

0

0

Denominator: CDC DM population

0 80 84 88 92 96

Adjusted incident rates of ESRD with diabetes as primary diagnosis, by age incident ESRD patients

10,000

2.18

Denominator: general population

0

0

Rate per million population

1,000

Rate per million population

4,000

Denominator: CDC DM population

Rate per million population

Rate per million population

5,000

01

02

03

04

05

00

01

02

Adjusted incident rates of ESRD with diabetes as primary diagnosis, by age & race incident ESRD patients

03

04

05

rates of ESRD in high-density areas INCIDENCE & PREVALENCE

.

White

MSA

S88

New York, NY Los Angeles, CA Chicago, IL Philadelphia, PA Dallas-Fort Worth, TX Miami, FL Washington, DC Houston, TX Atlanta, GA Detroit, MI Boston, MA San Francisco-Oakland, CA Riverside-San Bernadino, CA Phoenix, AZ Seattle, WA Minneapolis-St Paul, MN San Diego, CA St. Louis, MO Baltimore, MD Tampa, FL Pittsburgh, PA Denver, CO Cleveland, OH Cincinnati, OH Portland, OR

2.a

Prev

275 351 295 237 224 211 213 317 222 284 216 245 339 278 213 219 261 247 265 199 288 209 284 286 230

1,090 1,503 1,236 991 1,073 865 783 1,211 852 1,095 962 1,046 1,375 1,108 939 1,027 1,216 1,002 989 860 1,193 999 1,161 1,125 1,046

White Incident Prevalent

New York, NY Los Angeles, CA Chicago, IL Philadelphia, PA Dallas-Fort Worth TX Miami, FL Washington, DC Houston, TX Atlanta, GA Detroit, MI

1.09 1.39 1.17 0.94 0.89 0.84 0.85 1.26 0.88 1.13

1.03 1.42 1.17 0.93 1.01 0.82 0.74 1.14 0.80 1.03

794 879 963 926 1,036 750 953 1,130 921 1,071 728 952 878 1,033 718 1,114 868 1,080 1,073 986 1,345 738 1,085 980 753

3,614 3,851 4,485 4,888 5,148 3,452 4,234 4,795 4,337 5,040 3,793 4,524 3,954 3,788 4,325 5,299 4,495 5,301 4,819 4,190 5,882 4,188 5,391 5,416 4,512

Inc

Other Prev

280 359 258 245 302 215 302 239 307 357 389 352 383 717 345 564 367 * 224 351 * 289 * * 329

1,170 1,640 1,315 1,116 1,433 1,111 1,302 1,084 1,057 1,391 1,304 1,806 1,740 3,769 1,819 2,926 1,852 1,006 987 1,291 879 1,340 1,303 1,085 1,983

Hispanic Inc Prev 377 575 501 443 441 209 305 562 180 598 351 401 532 602 299 773 567 418 261 241 * 488 504 * 399

1,496 2,478 2,077 1,594 2,327 940 1,102 2,219 829 1,980 1,587 1,669 2,238 2,438 1,529 2,722 2,616 5,253 1,584 1,343 759 2,127 1,925 612 1,842

African American Incident Prevalent 0.78 0.87 0.95 0.91 1.02 0.74 0.94 1.12 0.91 1.06

0.73 0.78 0.91 0.99 1.04 0.70 0.86 0.97 0.88 1.02

Other Incident Prevalent 0.73 0.94 0.68 0.64 0.79 0.56 0.79 0.62 0.80 0.93

0.69 0.97 0.78 0.66 0.85 0.66 0.77 0.64 0.63 0.82

Relative rate of ESRD, by metropolitan statistical area (MSA) & race incident & December 31 point prevalent ESRD patients, 2005

White

African American

330 + (381) 296 to <330 267 to <296

2.20

African American Inc Prev

Incident & prevalent rates (per million population) of ESRD, by metropolitan statistical area (MSA) & race incident & December 31 point prevalent ESRD patients, 2005

MSA

2.b

Inc

234 to <267 below 234 (200)

833 + (937) 717 to <833 603 to <717

Geographic variations in adjusted incident rates (per million population) of ESRD, by race & HSA incident ESRD patients, 2005

I

ncident rates by metropolitan statistical area (MSA) for whites exceed 300 per million population in the Los Angeles, Riverside-San Bernadino (California), and Houston areas; the lowest rate is found in the Tampa-St. Petersburg MSA, at 199 per million (Table 2.a). Rates for African Americans exceed 1,000 per million population in the DallasFort Worth, Houston, Detroit, Phoenix, Minneapolis-St. Paul, St. Louis, Baltimore, and Cleveland MSAs, and are highest in the Pittsburgh area, at 1,345 per million population. Incident rates for Hispanics are highest in the Minneapolis-Saint Paul area, at 773, while prevalent rates exceed 5,000 per million population for those residing in the St. Louis, Missouri, area. The relative rate of ESRD amongst white incident patients is highest in the Los Angeles and Houston areas, at 1.39 and 1.26, respectively (Table 2.b). Patients residing in the Los Angeles and Chicago areas have the highest prevalent rate, at 1.42 and 1.17, respectively. Incident relative rates of ESRD for African Americans are highest for those residing in and around Houston, at 1.12, while prevalent rates are highest for those living in the Dallas-FortWorth areas, at 1.04. Geographic patterns show that incident rates for whites are highest in areas of the Southwest, south Texas, and portions of the Ohio Valley, and average 381 per million population for patients residing in areas represented

Other race

502 to <603 below 502 (455)

316 + (455) 244 to <316 194 to <244

151 to <194 below 151 (131)

2007 USRDS Annual Data Report by the upper quintile (Figure 2.20). Rates for African Americans are nearly three times those found in whites, and are highest in the south, mid-south, and along the Eastern Seaboard. Figure 2.21 shows unadjusted incident and prevalent rates and adjusted incident rates of ESRD by MSA. Rates are considerably higher by MSA when compared to overall rates across the country. The overall unadjusted incident rate in 2005 was 347 per million population, while rates in higher density areas appear to be nearly three times greater. These differences may reflect different burdens of chronic kidney disease, as well as regional differences in the use of detection efforts and treatment interventions in populations at risk for kidney failure. Ŧ

Incident rates: unadjusted

1,500 750 150 White African Amer. Other

Incident rates: adjusted (for age & gender)

DOO oJXUHV  WDEOHV incident & December 31 point prevalent (Figure 2.20, incident only) ESRD patients, 2005. ŧ WDEOHD adjusted for age & gender; race & Hispanic ethnicity are not mutually exclusive. *Values for ten or fewer patients are suppressed. WDEOH E relative rates of ESRD are based on the median rate for all MSAs. oJXUH HSA; adjusted for age & gender. Excludes patients residing in Puerto Rico & the Territories.

To read MSA maps

1,800 900

Circles represent the summed total of the rates established for each race in their respective MSA.

180 White

ŧ

African Amer.

Racial segments represent the proportion of the total rate. ŧ

Other

Prevalent rates: unadjusted

Circle size is graduated relative to the summed total rate in each MSA. ŧ

Adjusted incident rates in the Dallas MSA, for example, are below 900 per million but greater than 180 per million.

6,500 3,250 650 White African Amer. Other

2.21

Geographic variations in incident & prevalent rates (per million population) of ESRD, by MSA & race incident & December 31 point prevalent ESRD patients, 2005

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prevalence

12

800

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4

0

0 80

82

84

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N Am (57.7) Asian (59.0) Hispanic (57.1) All (58.6)

45 40 78

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02

Median age of prevalent patients December 31 point prevalent patients

A

djusted prevalence of ESRD reached 1,569 in 2005, 1.4 times greater than in 1995 (Figure 2.22). Annual growth in the rate, however, has slowed, and has been 3.0 percent or lower since 2001. More than 350,000 prevalent patients live in urban areas, and 112,000 in areas classified as rural (Figure 2.23). The median age of prevalent patients is now 58.6, and it varies little by race or ethnicity, ranging from a low of 56.6 in African Americans to a high of 59.7 in whites (Figure 2.24). Nearly one in five prevalent patients is age 65–74, and 16 percent are age 75 or older (Figure 2.25). The numbers of patients age 45–64 and age 75 and older have grown 32 percent since 2000; the population age 20–44, in contrast, seems to have plateaued, increasing only 5 percent during the same period. The prevalent rate in 2005 topped 5,500 per million among those age 65–74, and neared 4,800 for those 75 and above. Across age

0-19 20-44 45-64 65-74 75+

150 100 50 0 80

2.25

2.26

Rate per million population

50

Counts 200

84

88

92

96

00

Urban 300 200 100 Rural 0 80

6,000

84

88

92

96

00

04

Prevalent counts, by geographic location December 31 point prev. ESRD pts Rates 0-19 20-44 45-64 65-74 75+ All

4,500 3,000 1,500 0

04

80

84

88

92

96

00

04

Prevalent counts & adjusted rates, by age December 31 point prevalent ESRD patients

280

Counts Male

210 Female

140 70 0 80

84

88

92

96

00

04

Rate per million population

55

Number of patients (in thousands)

White (2005: 59.7) Af Am (56.6)

400

2.23

Adjusted prevalent rates & annual percent change December 31 point prevalent ESRD patients

60

2.24

92

Number of patients (in thousands)

1,200

Symbols: one-year % change

16

2.22 Median age (in years)

S90

1,600

Number of patients (in thousands)

Bars: Rate per million population

INCIDENCE & PREVALENCE

2,000

Rates Male All

1,500 Female

1,000 500 0 80

84

88

92

96

00

04

Prevalent counts & adjusted rates, by gender December 31 point prevalent patients

groups, however, the one-year rate of the upper quintile has increased nearly growth was less than 3 percent. 48 percent since 2000. As in the incident population, differBy race, the number of prevalent white, ences by gender continue to grow (Figure African American, and Native American 2.26). The number of males in the prevalent patients rose 20–23 percent between 2000 population increased 25.6 percent between and 2005, while the number of Asian 2000 and 2005, compared to 20.3 percent patients grew 39 percent (Figure 2.28). for females. And the prevalent rate for The rate per million population rose males grew 14.0 percent, to 1,905 per mil- nearly 15 percent for whites and 8–9 perlion population, while that for females rose cent for African Americans and Asians; 9.9 percent, to 1,291. that for Native Americans, in contrast, fell In the prevalent population, geographic 1.1 percent. Significant differences by race variations in ESRD rates have remained persist, with the 2005 rates per million quite consistent since 2000 (Figure 2.27). population of 4,863 and 2,669 for African The highest rates continue to occur in the Americans and Native Americans, respecDakotas and across the southern states tively, being 4.2 and 2.3 times higher than from California to Texas. The mean rate in the rate of 1,151 found among whites.

2007 USRDS Annual Data Report 2005

2000

Rate per million population

Counts White African American Native American Asian

200

100

0 80

84

88

92

96

00

Rates White African American Native American Asian All

4,000 3,000 2,000 1,000 0

04

80

84

88

92

96

00

04

Counts Non-Hispanic

400 300 200 100

Hispanic

0 96

2.29

98

00

02

Rate per million population

Prevalent counts & adjusted rates, by race December 31 point prevalent patients

500

2,500

Rates Hispanic/all

2,000 All 1,500 Non-Hispanic 1,000

04

96

98

00

02

04

Prevalent counts & adjusted rates, by Hispanic ethnicity December 31 point prevalent patients

200

Counts Diabetes Hypertension Glomerulonephritis Cystic kidney

150 100

2.30

5,000

Rate per million population

DOO oJXUHV December 31 point prevalent ESRD patients. ŧ oJXUHrates adjusted for age, gender, & race. oJXUHlocation determined using ZIP code of patient residence. oJXUHrates adjusted for gender & race. oJXUHrates adjusted for age & race. oJXUHby HSA; adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories. oJXUHVqrates adjusted for age & gender. oJXUHrates adjusted for age, gender, & race. ŧ For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

300

2.28 Number of patients (in thousands)

As mentioned in regard to incidence, the 2005 revision of the Medical Evidence form now eliminates the classification of Hispanic Mexican, and offers two choices of Hispanic ethnicity—“Not Hispanic or Latino,” and “Hispanic or Latino.” In 2005, the prevalence of ESRD among Hispanics was 47 percent higher than that found in nonHispanics (Figure 2.29). And when using the new classification system, rates for Hispanics increased nearly 40 percent between 1996 and 2005, compared to an increase of 34 percent in the non-Hispanic population. By primary diagnosis, adjusted rates of diabetes remain high but appear to be leveling off, as evidenced by more moderate growth beginning in 2000 (Figure 2.30). Rates of diabetes between 1995 and 2000, for example, increased 39 percent. Rates between 2000 and 2005, in contrast, grew by less than half that, at 15.6 percent. In 2005, rates of diabetes stood at 578 per million population compared to rates for hypertension, glomerulonephritis, and cystic kidney disease, at 382.7, 254.4, and 73.3, respectively. Ŧ

Number of patients (in thousands)

Geographic variations in adjusted prevalent rates (per million population), by HSA December 31 point prevalent patients

Number of patients (in thousands)

2.27

S91

1,717 + (1,999) 1,584 to <1,717 1,472 to <1,584 1,338 to <1,472 below 1,338 (1,233)

1,208 + (1,355) 1,122 to <1,208 1,066 to <1,122 1,003 to <1,066 below 1,003 (944)

50 0 80

84

88

92

96

00

04

600

Rates

450 300 150 0 80

84

88

92

Prevalent counts & adjusted rates, by primary diagnosis December 31 point prevalent patients More on prevalent patient counts & rates: p.a, p.2–3 & p.7, Chapter Four, 8.13–14 (pediatric patients).

96

00

04

projected ESRD counts & costs through 2020 200 Original proj. model 1: 2010, 129,200 Original proj. model 2: 2010, 172,667 New projection: 2020, 143,693 (95% CI: 70,161 - 263,569) Actual: 2005, 106,912

150 100 50 0 80

2.31

84

88

92

96

00

04

08

12

16

Total dollars (in billions)

20

0 92

Number of patients (in thousands)

2.33

96

00

04

08

12

16

20

Projected ESRD expenditures through 2020 (autoregression model)

600 Original projection: 2010, 520,240 New projection : 2020, 525,885 (95% CI: 246,858 - 988,414) Actual: 2005, 341,319

500 400 300 200 100 0 80

2.34

84

88

92

96

00

04

08

12

16

20

12

16

20

Projected counts of prevalent dialysis patients through 2020 (autoregression model)

300 Original projection: 2010, 178,806 New projection: 2020, 257,927 (95% CI: 232,633 - 283,220) Actual : 2005, 143,693

250 200 150 100 50 0 80

2.35

84

88

92

96

00

04

08

Projected counts of prevalent transplant patients through 2020 (autoregression model)

Original projection: 2010, 651,330 New projection: 2020, 785,552 (95% CI: 460,374 - 1,255,436) Actual: 2005, 485,012

600 400 200 0 80

2.32

Original projection: 2010, $28.3 New projection : 2020, $53.6 (95% CI: $8.7 - $181.2) Actual : 2005, $21.4

40

800

20

Projected counts of incident ESRD patients through 2020 (autoregression model)

60

Number of patients (in thousands)

S92

Number of patients (in thousands)

Number of patients (in thousands)

INCIDENCE & PREVALENCE

84

88

92

96

00

04

08

12

16

20

Projected counts of prevalent ESRD patients through 2020 (autoregression model)

I

n published papers the USRDS has used two methods to project future ESRD counts, one with available data through 1997 and projecting to 2010 (Xue et al.), and one with available data through 2000 and projecting to 2015 (Gilbertson et al.). The first method used a forecasting methodology with a stepwise autoregressive technique and exponential smoothing, while the second was based on a Markov model. Here we revisit both methods, using data available through 2005, and projecting to 2020. Figures 2.31 and 2.36 compare newly projected incident counts to original projections, using the autoregression and Markov models, respectively. The original autoregression projection consisted of a conservative, more linear projection (in Figure 2.31, Model 1) and a less conservative, quadratic projection (Model 2). Both overestimated actual counts in 2005, with the more conservative projection doing so by approximately 21 percent. The updated projection, using data through 2005, produces an estimate of 143,963, similar to the 150,772 obtained in Figure 2.36 with the Markov model. The new autoregression projection produces a lower estimates for 2010 than did our previous projection. This is primarily a result of a slowing of the growth in incident counts from 2000 to 2005, itself due to continued flattening of the incident rates. This decreased growth in terms of patient counts, however, is not expected to continue, as the effect of the baby boomers, of changing patient distribution by race and ethnicity, and of a continued rise in the prevalence of diabetes will drive future increases in ESRD counts, even if there is no further growth in rates of ESRD. Figures 2.32 and 2.37 show projected prevalent ESRD counts using the autoregression and Markov models. Similar to those of incident counts, the new projections give slightly lower estimates for 2010 than did our previous estimates. Both models project approximately 785,000 prevalent ESRD patients by 2020. In Figure 2.33 we project total Medicare ESRD costs to 2020 (this estimate is not adjusted for inflation). With actual costs in 2005 of $21.3 billion, continued growth in ESRD counts—both prevalent and incident—is expected to double these expenditures before 2019, with costs of $53.6 billion in 2020. Projected prevalent counts for the dialysis and transplant populations are shown in Figures 2.34–35 and 2.38. While new immunosuppressive drugs, improved surgical techniques, and improved post-transplant care during the past decade

Original projection: (2015, 136,882) New projection: (2020, 150,772) Actual: (2005, 106,912)

120 80 40 0 80

2.36 Number of patients (in thousands)

Number of patients (in thousands)

160

84

88

92

96

00

04

08

12

600 500 400

light lines show actual counts

Dialysis: 2020, 533,800; 2005, 341,319

300 200 100

20

Tx: 2020, 250,813; 2005, 143,693

0

120 100

Proj. growth of prev. ESRD populations, by modality (Markov model)

80 60 40

800 Original projection: 2015, 713,531 New projection: 2020, 784,613 Actual: 485,012

600 400 200 0 80

2.37

80 84 88 92 96 00 04 08 12 16 20

2.38

16

Projected counts of incident ESRD patients through 2020 (Markov model)

Number of patients (in thousands)

Number of patients (in thousands)

2007 USRDS Annual Data Report

84

88

96

00

04

08

12

16

20

Projected counts of prevalent ESRD patients through 2020 (Markov model)

Incidence White: 2020, 100,288; 2005, 69,742 African American: 2020, 40,204; 2005, 30,227 Other: 2020, 1,028; 2005, 6,927 light lines show actual counts

500

Prevalence White: 2020, 488,688; 2005, 298,064 African Am.: 2020, 224,669; 2005, 151,801 Other: 2020, 71,256 2005, 35,130

400 300 200 100

20 0

0 80 84 88 92 96 00 04 08 12 16 20

2.39

92

80 84 88 92 96 00 04 08 12 16 20

Projected growth of incident & prevalent ESRD populations through 2020, by race (Markov model)

Number of patients (in thousands)

have enabled transplantation of older Incidence Prevalence 500 100 patients and of those with a higher Diabetes: 2020, 70,484; Diabetes: 2020, 293,843; 2005, 46,849 2005, 174,043 burden of comorbidity, transplanted 400 80 Other: 2020, 80,288; Other: 2020, 490,769 patients still currently account for just 2005, 60,047 2005, 310,943 30 percent of the prevalent ESRD popu300 60 light lines show lation, primarily due to organ availabilactual counts ity. The Markov model assumes a simi200 40 lar distribution, with this 30 percent 100 20 growing just slightly by 2020, while the autoregression model makes no such 0 0 assumption and separately extrapo80 84 88 92 96 00 04 08 12 16 20 80 84 88 92 96 00 04 08 12 16 20 lates actual dialysis and transplant counts. These methods lead to someProjected growth of incident & prevalent ESRD populations what different projections: for dialysis, through 2020, by primary diagnosis (Markov model) the Markov model estimates 533,800 patients by 2020, and the autoregresBy primary cause of renal failure, continued expected growth sion model 525,885. For transplant, projected counts are 250,813 and 257,927, respectively. Autoregression estimates suggest that in the prevalence of diabetes should lead to a further rise in dia33 percent of prevalent ESRD patients in 2020 will have a trans- betic renal failure. We project that patients with ESRD caused by diabetes will account for 47 percent of the incident ESRD popuplant, and 67 percent will be treated with dialysis. Projected incident and prevalent counts by race and primary lation, and 37 percent of the prevalent population, by 2020. Ŧ cause of renal failure are shown in Figures 2.39–40. By race, we project that the largest percent change between 2005 and 2020 will oJXUHVq oJXUHVq counts projected using forecasting & time series analybe among patients of races other than white or African Ameri- sis. Original projection uses two models with data from 1982 through 1997; new can. In the prevalent population, for example, counts of white and projection uses data from 1980 through 2005. oJXUHdollars projected using fore& time series analysis. Original projection uses data from 1982 through African American patients are estimated to grow 64 and 48 per- casting 1997; new projection uses data from 1991 through 2005. oJXUHVqcounts procent, while the number of patients of other races is expected to jected using a Markov model. Original projection uses data through 2000; new projection uses data through 2005. more than double—from 35,130 in 2005 to 71,256 in 2020.

2.40

S93

rare diseases

INCIDENCE & PREVALENCE

0.6

0.08

0.4

0.06

0.3

0.04

0.2

0.02

0.1

0.00

Rate per million population

Prevalence

0.5

0.0 96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.41

Rates of ESRD due to Fabry’s disease incident & December 31 point prevalent ESRD patients Incidence

Prevalence

24

3

18

2

12

1

6

0

Rate per million population

4 Rate per million population

0 96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.42

Rates of ESRD due to IgA nephropathy/Berger’s disease or IgM nephropathy incident & December 31 point prevalent ESRD patients

1.0

Incidence

Prevalence

5

0.8

4

0.6

3

0.4

2

0.2

1

0.0

Rate per million population

O

Incidence

0.10

Rate per million population

S94

n this spread we present data on the incidence and prevalence of ESRD due to some of the less frequently occurring primary diagnoses. In 2004–2005, the incidence of ESRD caused by Fabry’s disease—a lipid storage disorder—was 0.9 per million population, and the prevalence rose slightly to 0.5 (Figure 2.41). The incidence of ESRD due to IgA nephropathy/Berger’s disease or to IgM nephropathy was stable during the late 1990s and early part of this decade, then rose slightly in 2004–2005, reaching 3.2 cases per million population (Figure 2.42). Prevalence, in contrast, has grown steadily since 1996– 1997, reaching 22.1 in 2004–2005, and indicating that people are surviving longer with these diagnoses. Rates of ESRD caused by Wegener’s granulomatosis show a similar pattern of change (Figure 2.43). After stabilizing between 1998 and 2003, incidence rose in 2004–2005 to 1.0 per million population. Prevalence has risen steadily since 1996– 1997, reaching 4.6 in 2004–2005—a growth of 70 percent. Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body produces antibodies to its own proteins. The incidence of ESRD due to this disease has remained between 3.4 and 3.8 per million population since 1996–1997, while prevalence has grown 46.9 percent, reaching 28.4 in 2004–2005 (Figure 2.44). The rate of new cases of ESRD caused by secondary glomerulonephritis/vasculitis other than Wegener’s or SLE nephritis—a designation that includes scleroderma, hemolytic uremic syndrome, and nephropathy due to heroin or other drug abuse—has fallen very slightly, and is now 2.9 per million population (Figure 2.45). Prevalence has grown from 13.5 in 1996– 1997 to 16.4 in 2004–2005. Polycystic kidney disease is an inherited disorder marked by numerous cysts in the kidney, and usually appears later in life. Incidence of ESRD due to PKD has been steady since the mid-1990s, at 7.4–8.0 per million population, while prevalence has increased from 58.8 to 71.1 cases per million population— growth of 20.8 percent (Figure 2.46). The incidence of ESRD caused by Alport’s disease—also an inherited condition, marked by deafness and hematuria as well as kidney damage—and by other hereditary and familial diseases remains between 0.5–0.6 per million population, while prevalence grew slightly to reach 6.8 in 2004–2005 (Figure 2.47). For ESRD due to multiple myeloma or light chain nephropathy, rates of incidence and prevalence show a similar pattern—peaking in 2002–2003 at 4.7 and 5.9 per million population, respectively, then falling slightly in the following two-year period (Figure 2.48). New ESRD due to amyloidosis—in which insoluble proteins accumulate in the tissues and organs—has remained stable at 0.9 per million population since 2000, while prevalence has risen slightly from 2.0 in 1996–1997 to 2.2 in 2004–2005 (Figure 2.49).

Rate per million population

0.12

0 96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.43

Rates of ESRD due to Wegener’s granulomatosis incident & December 31 point prevalent ESRD patients

While the rate of new cases of ESRD due to AIDS has fallen slightly since the beginning of the decade—reaching 2.7 per million population in the 2004–2005 period—prevalence has grown steadily, reaching 8.9 in 2004–2005, and indicating that people are living longer with the disease (Figure 2.50). New cases of ESRD due to complications from a transplant seem to have spiked in 2004–2005, to 0.9 per million population; this growth may, however, be attributed to new codes on the revised Medical Evidence form that are related to post-transplant complications (Figure 2.51). Prevalence of ESRD from these complications reached 3.8 in 2004–2005. Ŧ oJXUHVqincident & December 31 point prevalent ESRD patients.

2007 USRDS Annual Data Report

20 2 10 1

2

10

1

5

2.45

4

40

2

20

0

6

0.5

5

0.4

4

0.3

3

0.2

2

0.1

1

0.0

0

2.47

5

5

4

4

3

3

2

2

1

1

0

Rates of ESRD due to Alport’s & other hereditary/familial disease incident & December 31 point prevalent ESRD patients

1.0

6 Rate per million population

Prevalence

Rate per million population

Rate per million population

Incidence

2.0

0.6

1.5

0.4

1.0

0.2

0.5

2.49

2

6

1

3

0

1.00

9

0

Rate per million population

Prevalence

Rates of ESRD due to AIDS incident & December 31 point prevalent ESRD patients

0.0

Rates of ESRD due to amyloidosis incident & December 31 point prevalent ESRD patients Incidence

Prevalence

4

0.75

3

0.50

2

0.25

1

0.00

96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.50

2.5

96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

Rate per million population

Rate per million population

Incidence

Prevalence

0.0

0

Rates of ESRD due to multiple myeloma & light chain nephropathy incident & December 31 point prevalent ESRD patients

3

Incidence

0.8

96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.48

0 96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

Rates of ESRD due to polycystic kidney disease incident & December 31 point prevalent ESRD patients

6

7

0.6

96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.46

Prevalence

Rate per million population

60

Incidence

Rate per million population

6

S95

Rates of ESRD due to other secondary glomerulonephritis/ vasculitis incident & December 31 point prevalent ESRD patients

0.7

80 Rate per million population

Prevalence

0 96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

Rate per million population

Rate per million population

Incidence

20 15

0

0

Rates of ESRD due to lupus erythematosus (SLE nephritis) incident & December 31 point prevalent ESRD patients

8

Prevalence

3

96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.44

Incidence

Rate per million population

3

0

4

30

0 96-97 98-99 00-01 02-03 04-05 96-97 98-99 00-01 02-03 04-05

2.51

Rates of ESRD due to post-transplant (non-renal) complications incident & December 31 point prevalent ESRD patients

Rate per million population

Prevalence

Rate per million population

Incidence

Rate per million population

Rate per million population

4

ESRD network populations

INCIDENCE & PREVALENCE

200

150

150

100

100

50

50

0

0

2.54

2

3

4

5

6

7

150

200

100

100

50

0

Green: Rate per million, 2005

300

0 1

2

3

4

5

6

7

8 9 10 11 12 13 14 15 16 17 18 ESRD network

Hypertension, 1995–2005 incident ESRD patients 80

40

60

30

40

20

20

10

0

0

-20

All

1

2

3

4

5

6

7

8 9 10 11 12 13 14 15 16 17 18 ESRD network

-10

Glomerulonephritis, 1995–2005 incident ESRD patients

Incident

64.9 + (66.3) 63.9 to <64.9 62.4 to <63.9

2.55

8 9 10 11 12 13 14 15 16 17 18 ESRD network

Diabetes, 1995–2005 incident ESRD patients

All

2.53

1

Green: Rate per million, 2005

Blue: Percent growth, 1995 to 2005

2.52

Green: Rate per million, 2005

200

All

Blue: Percent growth, 1995 to 2005

S96

Blue: Percent growth, 1995 to 2005

Growth in incident ESRD populations, by primary diagnosis & network

Prevalent

60.9 to <62.4 below 60.9 (59.8)

59.1 + (59.8) 58.4 to <59.1 57.7 to <58.4

Geographic variations in mean age, by HSA & ESRD network, 2005 incident & December 31 point prevalent ESRD patients

57.0 to <57.7 below 57.0 (56.4)

B

etween 1995 and 2005, the number of new patients with diabetes as the cause of ESRD grew nearly 60 percent, and the rate per million in 2005 reached 151.9 (Figure 2.52). Network 1 exhibited the lowest rate of growth in new cases, at 33.6 percent, and Network 14 the highest, at 79.9 percent. Rates of diabetic ESRD range from 94.4 per million population in Network 16 to nearly 190 in Network 14—25 percent higher than the rate for all networks combined. Rates exceeding 170 per million population are evident in Networks 5, 6, 8, 9, and 13. The number of new ESRD cases attributed to hypertension grew 52 percent in 2005, while the rate per million population was 61 percent lower than that of diabetic ESRD (Figure 2.53). Network 15 shows the most significant growth in the number of new cases— 91.7 percent—compared to 30.6 percent in Network 2. The rate is highest in Network 8, at more than 140 per million population, and lowest in Network 16, at 47.6. Rates exceeding 120 are evident in Networks 5, 6, and 13. New cases of ESRD caused by glomerulonephritis fell 2.3 percent overall in 2005 (Figure 2.54). Ten-year change varies widely among networks, from a rise of 23.2 percent in Network 15 to a decrease of 21.8 in Network 10. Rates per million population vary less than rates of ESRD due to diabetes or hypertension, from a high of 32.7 in Network 3 to a low of 20.8 in Network 14. In Network 16, the 3.0 percent growth in 2005 is significantly less than growth rates of 58.7 and 71.6 percent, respectively, found in patients with diabetes or hypertension. Mean age is greatest across the northern half of the country and Florida (Figure 2.55). From the lower to the upper quintiles, mean age varies from 59.8 to 66.3 and 56.4 to 59.8, respectively, among incident and prevalent patients. Tables 2.c–e present adjusted patient demographics and disease rates by modality in 2005. Rates per million for incident dialysis patients range from 221 in Network 16 to 413 in Network 8. In 11 of 18 networks the rate exceeds that of the overall population.

2007 USRDS Annual Data Report 16

11

2 4

17/ 18

10

12

15

13

9 8

1 3

5 6

14 16

7 17

Network 1 Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont Network 2 New York Network 3 New Jersey, Puerto Rico, Virgin Islands Network 4 Delaware, Pennsylvania Network 5 Maryland, Virginia, Washington D.C., West Virginia Network 6 Georgia, North Carolina, South Carolina Network 7 Florida Network 8 Alabama, Mississippi, Tennessee Network 9 Indiana, Kentucky, Ohio Network 10 Illinois Network 11 Michigan, Minnesota, North Dakota, South Dakota, Wisconsin Network 12 Iowa, Kansas, Missouri, Nebraska Network 13 Arkansas, Louisiana, Oklahoma Network 14 Texas Network 15 Arizona, Colorado, Nevada, New Mexico, Utah, Wyoming Network 16 Alaska, Idaho, Montana, Oregon, Washington Network 17 American Samoa, Northern California, Guam, Hawaii Network 18 Southern California

2.56

ESRD networks

In the point prevalent dialysis population, rates per million range from 680 in Network 16 to 1,390 in Network 8 and 1,428 in Network 6. African Americans tend to constitute a large proportion of the patient population in networks with the highest point prevalence. Transplant rates are highest in Network 11, at 713 per million population. Network 7, representing the Upper Midwest, accounted for 11.2 percent of the total transplants performed in 2005. Ŧ oJXUHV q incident ESRD patients; rates adjusted for age, gender, & race. oJXUHincident & December 31 point prevalent ESRD patients, 2005, by HSA, unadjusted. Excludes patients residing in Puerto Rico & the Territories. WDEOH Fincident dialysis patients. WDEOHGDecember 31 point prevalent dialysis patients. * Values for cells with ten or fewer patients are suppressed. WDEOHH December 31 point prevalent transplant patients. ŧ WDEOHV FqH counts & percentages include all patients in each network; rates, however, are calculated for the U.S. population only, & exclude patients with unknown age, gender, race, or network. Rates adjusted for age, gender, & race. ŧ A list of network contacts can be found on page S258 of Appendix A.

Total % of Rate per Network patients total million 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 All

2.c

3,771 6,947 4,603 5,109 6,311 8,776 6,498 5,649 8,204 4,517 7,234 4,047 4,238 8,332 4,584 2,903 4,957 7,808

% White

% Af Am

% N Am

% Asian

% Hisp.

259.7 347.3 376.1 380.3 398.3 391.9 357.1 413.1 368.7 342.1 320.7 301.2 383.9 356.9 251.1 220.9 319.9 326.8

65.9 63.8 64.3 65.1 61.9 60.1 64.0 60.5 63.9 63.0 64.0 63.8 61.7 60.2 61.2 63.5 62.2 62.1

39.1 40.6 48.8 42.4 42.7 43.7 42.0 41.2 45.9 39.7 41.8 42.1 44.1 53.2 50.7 42.4 48.0 46.1

82.5 61.0 66.4 73.4 48.5 41.6 67.1 49.3 74.9 62.3 72.0 77.1 54.9 71.5 78.5 84.0 57.6 69.4

13.6 31.7 25.8 24.9 48.2 56.0 29.6 49.1 24.0 32.5 23.5 21.0 39.3 25.6 8.8 6.1 13.6 14.9

0.2 0.4 0.2 0.1 0.2 0.7 0.3 0.4 0.1 0.1 2.5 0.7 4.4 0.4 8.9 3.3 0.9 0.5

2.8 4.4 2.9 1.1 2.3 1.2 1.6 0.6 0.5 2.5 1.6 0.9 0.8 1.7 3.3 6.3 26.1 11.3

6.5 13.5 33.8 2.5 2.6 2.0 13.3 0.7 1.7 10.1 2.9 2.8 2.4 38.4 24.0 7.0 18.8 38.8

104,488 100.0

340.1

62.7

44.4

65.0

28.7

1.1

3.8

13.0

Patient demographics & adjusted rates, by network: incident dialysis patients, 2005 incident dialysis patients

1 11,524 3.4 2 23,119 6.8 3 14,011 4.1 4 15,014 4.4 5 20,649 6.1 6 32,456 9.5 7 19,456 5.7 8 19,086 5.6 9 24,811 7.3 10 14,523 4.3 11 21,488 6.3 12 12,784 3.8 13 13,354 3.9 14 29,904 8.8 15 15,267 4.5 16 9,020 2.6 17 17,709 5.2 18 27,143 8.0 Unknown * All 341,319 100.0

Mean age

% Diabetic

% White

% Af Am

% N Am

% Asian

% Hisp.

784 1,140 1,128 1,109 1,291 1,428 1,051 1,390 1,112 1,108 949 946 1,204 1,262 824 680 1,119 1,158

64.0 61.8 61.7 63.1 60.1 58.5 61.3 58.7 61.7 61.5 62.6 61.9 59.2 58.7 60.5 61.4 61.2 60.4

38.3 39.4 44.5 40.7 39.3 40.8 39.4 39.6 43.6 38.9 41.4 40.9 42.5 51.3 51.8 41.7 46.9 45.2

75.2 50.1 56.4 62.5 36.9 30.3 55.5 36.8 64.4 53.8 62.2 67.7 42.7 65.4 71.0 77.9 49.0 68.0

19.9 40.8 33.6 35.3 59.3 67.2 40.9 62.0 34.3 41.7 32.0 29.8 51.0 31.0 10.5 9.3 16.7 17.2

0.3 0.5 0.1 0.2 0.1 0.6 0.2 0.4 0.1 0.1 3.2 1.1 5.0 0.3 14.3 4.5 1.0 0.5

2.7 4.7 2.9 1.1 2.3 0.9 1.8 0.5 0.6 2.8 2.1 1.2 0.8 1.8 3.5 8.0 30.5 12.6

8.0 14.1 33.7 3.3 2.8 2.3 14.5 0.7 2.1 10.9 3.7 5.6 2.4 41.7 28.1 8.6 21.0 43.0

1,103

60.8

42.9

55.3

37.2

1.5

4.4

14.8

Patient demographics & adjusted rates, by network: point prevalent dialysis patients, 2005 December 31 point prevalent dialysis patients

Total % of Rate per Network patients total million 1 7,125 5.0 2 8,708 6.1 3 4,002 2.8 4 8,636 6.0 5 8,834 6.2 6 8,329 5.8 7 7,173 5.0 8 6,784 4.7 9 10,469 7.3 10 6,292 4.4 11 16,131 11.2 12 6,599 4.6 13 4,455 3.1 14 9,675 6.7 15 7,061 4.9 16 5,533 3.9 17 7,372 5.1 18 10,324 7.2 Unknown 191 0.1 All 143,693 100.0

2.e

% Diabetic

3.6 6.7 4.4 4.9 6.0 8.4 6.2 5.4 7.9 4.3 6.9 3.9 4.1 8.0 4.4 2.8 4.7 7.5

Total % of Rate per Network patients total million

2.d

Mean age

484.9 434.3 368.0 628.4 546.6 369.9 384.8 492.3 465.0 466.6 712.7 487.6 401.9 402.9 383.1 418.3 479.6 439.3 . 466.2

Mean age

% Diabetic

% White

% Af Am

% N Am

% Asian

% Hisp.

50.3 49.4 49.5 50.2 50.1 48.6 51.0 48.3 49.4 48.5 50.0 49.3 48.6 48.7 49.2 50.1 49.1 48.5 47.9 49.4

20.1 18.6 21.1 22.2 22.2 21.9 21.2 20.2 24.7 22.1 28.4 22.8 23.4 24.2 28.0 25.6 20.1 19.8 0.0 22.9

84.3 69.9 72.6 74.7 58.5 59.9 73.3 66.7 81.2 67.8 83.4 84.2 63.2 78.9 85.0 84.3 66.2 74.5 23.6 74.4

11.6 21.5 20.4 20.8 35.4 37.3 22.2 31.5 16.1 24.8 11.8 12.6 32.1 16.2 5.2 5.3 8.9 10.7 1.6 18.6

0.2 0.6 0.2 0.2 0.2 0.7 0.3 0.2 0.1 0.2 1.7 1.0 2.9 0.4 5.8 3.0 1.0 0.6 0.5 1.0

2.9 5.4 4.3 2.4 4.0 1.7 3.0 0.9 1.4 3.8 2.6 1.7 1.4 3.3 3.6 7.3 21.9 13.0 7.3 4.7

7.2 16.4 29.5 2.5 4.7 2.1 16.0 0.9 1.5 12.1 3.1 4.8 2.1 35.3 19.8 6.2 19.3 36.3 1.1 12.0

Patient demographics & adjusted rates, by network: point prevalent transplant patients, 2005 December 31 point prevalent transplant patients More on network populations: 10.3 & 10.6.

S97

chapter summary

INCIDENCE & PREVALENCE

incidence

S98

oJXUH  In 2005, the overall adjusted incidence of ESRD again remained stable, with the rate of 347 per million population only 1 percent higher than in 2001. oJXUHRacial disparities in the incidence of ESRD continue to be dramatic. Incident rates in 2005 ranged from 268 per million population among whites to 991 among African Americans, 516 among Native Americans, and 355 among Asians— 3.7, 1.9, and 1.3 times greater, respectively. oJXUHThe 2005 incident rate for Hispanic patients was 490 per million population, 1.5 times higher than that found among whites.

incident rates of ESRD based on at-risk populations

projections of counts & costs of ESRD oJXUHV    Updated projections of incident counts of ESRD through the year 2020, using the autoregression and Markov analytical models, show similar results of 143,693 and 150,722, respectively. oJXUHV    Using the autoregression and Markov models, projected prevalent counts of ESRD through 2020 are approximately 785,000.oJXUH Projected Medicare ESRD costs in 2020 are approximately $53.6 billion dollars.

oJXUHVq Based on data collected through surveillance programs, the incidence of diabetes in the United States has risen to 5.3 per 100 population, with the major growth occurring in those age 45 years and older.oJXUHVq Using the CDC diabetic data, it appears that ESRD due to diabetes has been declining since the mid-1990s. Data reported by the USRDS, in contrast, show the rate stablilizing in most populations over the last five years. With each method, however, the most important general finding centers on the slowing of rates of ESRD due to diabetes, which may reflect improved preventive care.

oJXUHThe prevalence of ESRD due to IgA nephropathy/Berger’s disease or IgM nephropathy has grown steadily since 1996–1997, reaching 22.1 per million population in 2004–2005, and indicating that people are surviving longer with the disease. oJXUHThe incidence of ESRD due to systemic lupus erythematosus has remained between 3.4 and 3.8 per million population since 1996–1997, while prevalence has grown 46.9 percent, reaching 28.4 in 2004–2005.

ESRD rates in high-density areas

ESRD network populations

WDEOHD Incident rates by Metropolitan Statistical Area for whites exceed 300 per million population in the Los Angeles, Riverside-San Bernadino (California), and Houston areas, while the lowest rates are found in patients living in the Tampa-St. Petersburg area, at 199 per million.oJXUH Geographic patterns show that incident rates for whites are highest in areas of the Southwest, south Texas, and portions of the Ohio Valley, and average 381 per million population for patients residing in areas represented by the upper quintile. Rates for African Americans are nearly three times those found in whites, and are highest in the south, mid-south, and along the Eastern Seaboard.

oJXUH Rates of diabetic ESRD per million population range from 94.4 in Network 16 to nearly 190 in Network 14—25 percent higher than the rate for all networks combined. oJXUHThe rate of new ESRD cases attributed to hypertension is highest in Network 8, at more than 140 per million population, and lowest in Network 16, at 47.6. oJXUH  Rates per million population of ESRD caused by glomerulonephritis vary less than rates of ESRD due to diabetes or hypertension, from a high of 32.5 in Network 4 to a low of 20.8 in Network 14. WDEOHHBy network, transplant rates are highest in Network 11, at 713 per million population.

rare diseases

prevalence oJXUHThe adjusted prevalence of ESRD reached 1,569 per million population in 2005, 1.4 times higher than in 1995. Annual growth in the rate, however, has slowed, and has been 3.0 percent or lower since 2001. oJXUHThe numbers of patients age 45–64 and age 75 and older have grown 32 percent since 2000; the population age 20–44, in contrast, seems to have plateaued, increasing only 5 percent during the same period. oJXUHSignificant racial differences in ESRD prevalence persist, with the 2005 prevalent rates per million population of 4,863 and 2,669 for African Americans and Native Americans, respectively, being 4.2 and 2.3 times higher than the rate of 1,151 found among whites.

maps

National means & patient populations for maps can be IRXQGLQWKH([FHOoOHIRUWKLVFKDSWHU‹RQRXUZHEVLWHDWZZZXVUGVRUJ