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.

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]

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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