Kidney Disease Hospitalizations, Deaths Down in United States

Bridget M. Kuehn

December 09, 2016

Kidney disease–related deaths and hospitalizations have declined during the last 2 decades, according to the US Renal Data System (USRDS) annual report.

The report provides an annual snapshot of data from the USRDS, a national data registry that collects information on patients with kidney disease in the United States. It was produced by the USRDS coordinating center at the University of Michigan Kidney Epidemiology and Cost Center and the Arbor Research Collaborative for Health, both in Ann Arbor, Michigan.

In addition to improvements in deaths and hospitalizations, the authors found that more patients on dialysis are receiving arteriovenous fistulas, which help reduce the risk for infection, and that the number of paired kidney donations has grown to account for 10% of living donor transplants.

Hospital admissions among patients with end-stage renal disease (ESRD) decreased 19%, going from 2.1 per patient per year in 2005 to 1.7 per patient per year in 2014, according to the USRDS report.

Moreover, between 1996 and 2014, mortality rates fell by 32% among patients receiving dialysis, going from 243 deaths per 1000 patient years to 164.4 per 100 patient years, and 44% in transplant recipients, going from 53 per 1000 patient years to 29.9 per thousand patient years.

Several factors may be contributing to these improvements, Rajiv Saran, MD, director of the USRDS coordinating center and a professor of internal medicine at the University of Michigan, Ann Arbor, told Medscape Medical News. In general, the US population is living longer, and primary care providers are assuming a larger role in kidney disease care, he explained.

"Perhaps we are seeing healthier patients coming into the ESRD pool," he said. Dr Saran and colleagues plan to analyze the data further to determine whether patients with ESRD might be coming into care with fewer or better-managed comorbities.

Another big contributor to the improvements may be falling rates of infection among patients receiving dialysis, Dr Saran noted. Better infection control in dialysis units may partly explain these falling rates, he said.

Decreased use of temporary, infection-prone dialysis catheters may also be helping. The report shows that use of such catheters among existing patients receiving dialysis declined from 27% to 18% from 2003 to 2014. Use of an arteriovenous fistula, a safer and more permanent form of vascular access, increased from 32% to 63% among existing patients receiving dialysis during the same period. An arteriovenous fistula is a surgically strengthened vein that provides long-term vascular access for dialysis and is recommended, as it provides better blood flow during dialysis and is less likely to become infected or cause a blood clot than catheters.

Transplants continue to provide good outcomes for patients with ESRD, but a mismatch between the numbers of patients in need and available kidneys contribute to long wait times. The transplant waiting list increased to include 88,231 candidates at the end of 2014, an increase from the 87,985 on the waiting list in 2013. Fewer than 18,000 transplants were performed in 2014.

Some clinicians have hoped that the emergence of paired donations would help alleviate the wait times. Paired donations occur when a living donor does not match the patient they hoped to donate to, and instead donates their kidney to someone who does match; their originally intended recipient then gets a kidney from the other patient's matching donor.

Dr Saran points out this is the first time the report included data on paired kidney donations; 552 were performed in 2015, accounting for about 10% of living donor transplants in 2014.

"We hope to track that over time," Saran said. "We think it'll increase over time."

Despite such improvements in care, chronic kidney disease remains a prevalent condition affecting an estimated 14.8% of US adults. It is also a very costly condition for Medicare, accounting for $50 billion, or 20% of Medicare spending, in 2014. Spending on ESRD accounted for $32.8 billion, or about 7% of Medicare's $435.6 billion total fee-for-service spending that year.

Although some of the data suggest kidney care is improving, Dr Saran told Medscape Medical News that much work remains to be done. He noted that the majority of patients with chronic kidney disease do not learn they have the condition until the condition is very advanced. Many patients do not get good transitional care as they progress into ESRD. For example, he explained, 80% of patients still start dialysis with a catheter, because plans to have an arteriovenous fistula created before needing dialysis are not made in advance.

"Even though mortality rates are going down, there's no room for complacency," Dr Saran said. "People aren't getting the preparatory care they need in the transition to dialysis. That is a practice pattern that needs to change if we are going to continue reducing mortality."

Dr Saran has disclosed no relevant financial relationships. A complete list of the report's coauthors' conflicts is available online.

"2016 USRDS Annual Data Report: Epidemiology of Kidney Disease in the United States." US Renal Data System. National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD. Full text

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