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What Actions Are Needed to Decrease Rising End-Stage Kidney Disease Trends?

  • Authors: News Author: Pam Harrison; CME Author: Charles P. Vega, MD
  • CME / ABIM MOC / CE Released: 5/13/2022
  • Valid for credit through: 5/13/2023
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Target Audience and Goal Statement

This activity is intended for primary care physicians, nephrologists, nurses, pharmacists, physician assistants, and other members of the healthcare team who treat and manage patients at risk for end-stage kidney disease.

The goal of this activity is that learners will be able to distinguish trends in end-stage kidney disease in the US.

Upon completion of this activity, participants will:

  • Analyze trends in the epidemiology of diabetes and end-stage kidney disease resulting from diabetes in the US
  • Distinguish US racial/ethnic groups in which the incidence of end-stage kidney disease is increasing the fastest
  • Outline implications for the healthcare team


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News Author

  • Pam Harrison

    Freelance writer, Medscape


    Disclosure: Pam Harrison has disclosed no relevant financial relationships.

CME Author

  • Charles P. Vega, MD

    Health Sciences Clinical Professor of Family Medicine
    University of California, Irvine School of Medicine
    Irvine, California


    Disclosure: Charles P. Vega, MD, has disclosed the following relevant financial relationships:
    Served as an advisor or consultant for: GlaxoSmithKline; Johnson & Johnson

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  • Amanda Jett, PharmD, BCACP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


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  • Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP

    Associate Director, Accreditation and Compliance
    Medscape, LLC


    Disclosure: Leigh A. Schmidt, MSN, RN, CMSRN, CNE, CHCP, has disclosed no relevant financial relationships.

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What Actions Are Needed to Decrease Rising End-Stage Kidney Disease Trends?

Authors: News Author: Pam Harrison; CME Author: Charles P. Vega, MDFaculty and Disclosures

CME / ABIM MOC / CE Released: 5/13/2022

Valid for credit through: 5/13/2023


Clinical Context

End-stage kidney disease (ESKD) takes a considerable public health, economic, and personal/familial toll on the well-being of US residents. The authors of the current study note that ESKD accounted for more than $37 billion spent by Medicare in 2019, which is approximately 7% of the total Medicare paid claims costs. The most common causes of ESKD are diabetes and hypertension: 47% of patients with incident ESKD have diabetes and 29% have hypertension. Both diabetes and hypertension are more common among persons of color compared with White adults in the US.

The epidemiology of ESKD and its associated risk factors is evolving. After a steady increase over the course of many years, the incidence rate of diabetes has leveled off since 2010. The incidence rate of ESKD related to diabetes has also leveled off, although previously it had been in decline for more than a decade. The current study reexamines the epidemiology of ESKD in the US.

Study Synopsis and Perspective

Over the course of the past 20 years, the number of existing patients with end-stage kidney disease (ESKD) approximately doubled, and the number of new patients with reported ESKD increased by 41.8%, according to new data from the Centers for Disease Control and Prevention.

Between 2000 and 2019, the number of existing patients with ESKD, meaning that they had kidney failure requiring dialysis or transplantation, increased by 118.7%, report Nilka Rios Burrows, MPH, from the National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia, and colleagues.

The authors project that ESKD will continue to increase because of population growth, aging, and the high prevalence of risk factors such as diabetes and hypertension, which were the leading causes of ESKD, accounting for 47% and 29% of patients starting ESKD treatment in 2019.

"Higher percentage changes in both incident and prevalent ESKD cases were among Asian, Hispanic, and Native Hawaiian or other Pacific Islander persons and among cases with hypertension or diabetes as the primary cause," the authors note.

But there is a clear message that action can be taken to try to reduce these numbers, Rios Burrows said, as evidenced by a successful intervention project among American Indians/Pacific Islanders.

"If you have patients who have diabetes or high blood pressure, think about their kidneys. Get them tested and get them in early treatment to control their blood pressure. If we can effectively manage this, the trend in new cases will level off," she told Medscape Medical News.

"We need to continue to put the pedal to the metal. We need to continue to get patients into treatment and management earlier to prevent the progression to kidney failure," she continued.

One of the goals of the Advancing American Kidney Health Initiative is to reduce the number of Americans who develop ESKD by 25% by 2030.

Treatment includes greater use of blood pressure-lowering drugs such as angiotensin-converting inhibitors and angiotensin-receptor blockers, as well as the newer type 2 diabetes agents, the sodium-glucose cotransporter 2 (SGLT2) inhibitors, which have all been shown to have kidney-protective benefits.

Some Success Among American Indians/Pacific Islanders

Using US Renal Data System (USRDS) data from 2000 to 2019, the researchers studied trends in existing and new ESKD cases. USRDS uses data from the Centers for Medicare & Medicaid Services (CMS) Medical Evidence Report form. The data include sociodemographic information, initial treatment date for patients diagnosed with ESKD, and the primary cause of ESKD.

They reviewed the number of new cases in a year (incidence) and the prevalence of cases, both new and existing, for the total number of cases at the end of the year.

The lowest percentage increase in new cases was seen among American Indian/Alaska Native persons, with a +25% change between 2000 and 2019.

Rios Burrows credits this to initiatives implemented by the Indian Health Service tribal and urban health facilities, supported by the Special Diabetes Program for Indians. This initiative has been associated with a 53% decline in rates of kidney failure from diabetes among American Indian/Alaska Native persons, she added.

"They have done a marvelous job at making sure that everyone at risk gets tested every year," Rios Burrows said.

By way of comparison, the increase in new cases of ESKD across the 20 years was 33% among Whites, 30% among Blacks, 84% among Hispanics, 150% among Asian Americans, and 97% among Native Hawaiians/Pacific Islanders.

Rios Burrows has reported no relevant financial relationships.

MMWR Morb Mortal Wkly Rep. Published online March 18, 2022.[1]

Study Highlights

  • Study data were drawn from the US Renal Data System, which collects information from Medicaid and Medicare services regarding patients treated for ESKD.
  • The current study focuses on the Medicare database. Medicare covers 80% of the cost of ESKD treatment in the US. Kidney care providers are instructed to enter new patients with ESKD into the database.
  • The main study outcome was a comparison of demographic data in comparing incident and prevalent cases of ESKD in 2000 and 2019.
  • There were 92,660 incident cases of ESKD in 2000 compared with 131,422 cases in 2019. The respective numbers of prevalent cases were 358,247 and 783,594.
  • From 34.9% to 42.3% of ESKD cases occurred among persons between the ages of 45 and 64 years; from 53.4% to 58.3% of cases occurred among men. Finally, from 44.7% to 55.2% of cases occurred among White patients.
  • The increase in incident cases of ESKD was 41.8% in comparing 2019 with 2000. The respective increase in prevalent cases of ESKD was 118.7%.
  • The increase in incident and prevalent case numbers of ESKD was driven by outsized increases among Asian, Native Hawaiian or other Pacific Islander, and Hispanic patients. American Indian/Alaska Native, White, and Black populations experienced a milder increase in rates of ESKD.
  • Although diabetes was the most common cause of ESKD, the biggest increase in ESKD between 2000 and 2019 was seen in cases associated with hypertension.
  • Limitations of the study: data were based only on patients whose treatment was reported to CMS; the primary cause of ESKD was generated from the CMS Medical Evidence report, which is based on clinician assessment and may be influenced by prior knowledge of existing diabetes or hypertension; under- or overcount of the actual number of ESKD cases in certain racial or ethnic groups could have resulted from differential classification in the CMS Medical Evidence Form.

Clinical Implications

  • The incidence rates of both diabetes and ESKD related to diabetes have leveled off in the US in recent years.
  • The current study finds that biggest increases in the case rate of ESKD have occurred among Asian, Native Hawaiian or other Pacific Islander, and Hispanic patients in the US.
  • Implications for the healthcare team: The current study demonstrates that the healthcare team should be active in reducing risk factors for ESKD, particularly among Asian, Native Hawaiian or other Pacific Islander, and Hispanic patients.


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