us renal data systemrds_booklet_2009

8/6/2019 US Renal Data Systemrds_booklet_2009

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United StatesRenalDataSystthe concise 2009 Annual Data Repo

Atla

Dise

Dise


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www.usrds.orgContains PDF les o the

chapters, reerence tables,

and the Researchers Guide;

PowerPoint slides o atlas

gures and USRDS coner-

ence presentations; Exceliles o the data tables;

notices regarding current

news and analyses; links

to related Internet sites;

and email addresses or

contacting the USRDS.

products &services othe USRDS

Reports & guidesAnnual Data Reports Available rom the Na-

tional Kidney and Urologic Disease Inormation

Clearinghouse, Inormation Way, Bethesda, MD

0-0; 00.1.0, [email protected].

nih.gov. ADR material is also published in the

American Journal o Kidney Diseases.AnnualData Report CD Contains the text and graphics

o the ADR, data tables, PowerPoint slides, and

the Researchers Guide.

Researchers GuideProvides a detailed description o the USRDS

database and o the USRDS Standard Analysis

Files; the basic reerence or researchers who

use USRDS data les. Available in PDF ormat

on the website.


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Requests or dataData requests: two-hour Questions and data re-

quests not answered by the ADR can be addressed

to the Coordinating Center; those requiring less

than two hours o sta time to ulll are processed

without charge.Data requests: more than twohours Questions and data requests that require

over two hours o sta time must be submitted inwriting and approved by the NIDDK Project Ofcer.

Fulllment is subject to sta availability, and costs

are assessed on a case-by-case basis. StandardAnalysis Files provide patient-specic data rom

the USRDS to support ESRD research. A standard

price list has been established or the les, and

users must sign a data release agreement with

the NIDDK. Custom data fles can be createdby the Coordinating Center

or projects requiring dataother than those in the SAFs.

An hourly rate o $11. will

be assessed or time spent on

the request, and users must

sign a data release agree-

ment with the NIDDK.

RenDER The USRDS Renal Data

Extraction and Reerenc-

ing (RenDER) System is

a querying application

that allows users to create

data tables and interactivemaps. It can be accessed at

www.usrds.org/odr/xren-

der_home.asp ollowing a

short registration; a tutorial

is also available on this site

to help new users.

Publications/Most USRDS research st

papers or presentation

Inormation rom prese

the USRDS website, w

and papers can be oun

Data requests & publ

USRDS Coordinating C

1 South th Street, S

Minneapolis, MN 0

1.. 1..Fax 1..ww

Data fle contacts

Shu-Cheng Chen, MS; s

Beth Forrest, BBA; bor


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T hus I say to you, wprompts to pursue thwish to have a sound

the orms o the subthe details o them, the second [step] tfrst well fxed in mpractice. And i yo

you will throw awaycertainly greatly prAnd remember to acrather than rapidity

Leonard

Timeline o event

in patient are

CKD & ESRD patient

population 6

Population & o

related to major dieae 8

Prevalene & odd o CKD 10

CKD patient omorbidity 11

Geographi variation in CKD 12

Identifation o CKD 13

Biohemial level & drug

therapy in CKD patient 14Hositalization in CKD patient 16

Mortality rik in CKD patient 17

Aute kidney injury: are

ater hosital diharge 18

Patient are & vaular ae

in the tranition to ESRD 20

xpenditure during the

tranition to ESRD 22

ESRD inidene 23

ESRD prevalene 24

ESRD projecion to 2020 2

linial are o ESRD patient 26

Mortality rate in inident

dialyi patient 27

Hosital admiion

or inecion 28Vaular ae plaement;

bacerial ulture 29

idney translantation 30

o o ESRD 31

ind the complete annual data report with details onanalytical methods & patient populations at www.usrds.org


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81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03 04

Omnibus Budget ReconciliationAct (OMBA) includes Medicare

Secondary Payor provision

Composite rate payment

system or dialysis

becomes eective;

cyclosporine introduced

1972 Congress authorizes

medical coverage o ESRD

1978 Congress authorizes

creation o ESRD networks

EPO receives FDAapproval; USRDS

publishes rst ADR

USRDS

created

Center or Medicar

& Medicaid Service

(CMS) launche

Fistula First initiativU.S. Dept. o

Health & Human

Services develops

Healthy People2000 initiative

United Network

or Organ Sharing

(UNOS) created

60,000

patients

receive

treatment

or ESRD

UNOS begins to

operate the Organ

Procurement &

Transplantation

Network (OPTN)

National Kidney

Foundation (NKF)

launches the Dialysis

Outcomes Quality

Initiative (KDOQI)

NKF publishes KDOQI

guidelines; Health Care

Financing Administration

(HCFA) begins Hematocrit

Measurement Audit program

Timeline o events in patient care


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5pg 6

S k U S (V O, T .)NHANES participants age 20 & older. *Estimate not reliable. Data showpercentage o patients in each cell o let-hand column who have CKD, by stage.

NHANES III 19881994 NHANES 19992002 NHANES 200320Stage 1 Stage 2 Stage 3 Stgs 45 Stage 1 Stage 2 Stage 3 Stgs 45 Stage 1 Stage

0- . 1. 0. 0* . 1. 0. 0.* . 1.

0- . .1 . 0* . . . 0.* .

0+ . . 0. 1.1 . .1 . 1. . .

Male . . . 0. .0 . . 0. .

Female .0 .0 . 0. . . . 0. .

Non-Hispanic white . . . 0. . . . 0. .0 .

Non-Hisp. Arican American . . . 0. . . .1 1. .

Other . . . 0.* . . . 0.* .0

Sel-reported diabetes . 1. 1. 1. 10. 1. 1. . . 1

Sel-reported hypertension . .1 1. 0. . . 1. 1. .

Sel-reported CVD . . 1.0 0. .1 .0 .0 . .

Current smoker .1 .0 . 0.* .0 . . 0.* .

Obese (BMI 0 kg/m) . .0 . 0.* . . . 0.* .

COPD . . . 0.* . . .0 0.* .1

Hepatitis C . .* .* 0.* .* * .* 0* .* .

All . . . 0. . .1 . 0. .1

CKD & ESRD patient populations


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S esrd U S, 2007 (V T, T .)Dialysis & transplant patients, 2007.

Incidence December 31 point prevalence Kidney tranAdj. Adj. Deceased

Count % rate Count % rate Dialysis % Tx % donor

Age

0-1 1,0 1. 1 , 1. ,00 0. , .

0- 1,1 1. 1 ,1 1. ,0 1. ,11 .0 ,

- ,1 .0 11 ,10 . , 1,1 1. 1, 1. ,1

- , . 1, 10,1 1. ,0 , . ,0 1. 1,1

+ , . 1, ,1 1. ,1 , 1.1 , .1 0

Race

White , . 1, 1.0 1, 0,1 . 11,0 .1 ,0

Arican American 1,1 . 1, 1. ,111 1, .1 0,10 1.0 ,

Native American 1, 1.1 ,0 1. ,1 , 1. 1,0 1.1 1

Asian/Pacic Islander ,10 . ,0 . 1,11 1,0 . , .

Eth.

Hispanic 1,0 1. 0 ,0 1. ,0 ,0 1. 0,0 1. 1,

Non-Hispanic , . ,0 . 1,1 10,0 . 1, . ,

Gen.

Male , .1 , . ,0 0,11 . ,1 . ,0

Female , . 0, . 1, 1, .1 ,1 0. ,

Prim.d

iag. Diabetes ,1 .0 1 1,0 . 1 10, . ,1 .1 ,

Hypertension 0, . 1, . 0 10, .1 , 1. ,0

Glomerulonephritis ,1 . 1, 1. 0 , 10. ,1 . ,

Cystic kidney disease , . , . , . 1, .

Urologic disease 1, 1. 1,1 . , .0 , . 1

All 111,000 , 1, , 1, 11,

Unadjusted rate 1 1, Total transplants


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DM

5.0% CVD 11.8%

CKD 12.7%

COPD +

CKD 2.3%

COPD 10.7%w/o CKD

NHANES III 1988-1994

DM

7.6%CVD 9%

COPD +

CKD 3%

COPD 14.9%w/o CKD

CKD 15.1%

NHANES 2003-2006

5pg 8

D nhanes , v , v k cKd (V O, F 1.1)NHANES participants age 20 & older. CKD identifed using the creatinine (MDRD) ormula.

Populations & costs related to major diseases


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General Medicare: population, 2007(n=26,313,160; mean age 75.5)

General Medicare: costs, 2007($208.8 billion)

DM24.8%

CVD 49.4%

COPD 13.7%w/o CKD

COPD +CKD 3.2%

CKD 9.8%

DM38.7%

CVD 82.0%

COPD 23.8%w/o CKD

COPD +CKD 13.2%

CKD 27.6%

D v M k ,v , v , , 2007 (V O, F 9.1)Period prevalent non-ESRD Medicare patients age 65 & older, 2007.


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5pg 10

Pv cKd nhanes , f , cKd , ,, /, v ( ; V O, T 1.)NHANES participants age 20 & older; creatinine-based eGFR (NHANES 19992006) estimated by MDRD method,cystatin C-based eGFR (NHANES 19992002) estimated by cystatin C only, & only available or NHANES 19992002.

Creatinine-based eGFR Odds of CKD Cystatin C-based eGFR Odds of C

St 1 St 2 St 3 St 4-5 OR LCL UCL p-value St 1 St 2 St 3 St 4-5 OR

0- . 1. 0. 0.1* reerence . 1.* 0.* 0.* reerenc

0- . . . 0. 1. 1. 1. 0.000 . . . 0.* 1.0

0+ . . . 1. . . . 0.000 . . 1. .0 .

Male . .1 .0 0. reerence . . . 0. reerenc

Female . .1 . 0. 1. 1. 1. 0.000 .0 .0 . 0. 1.

Non-Hispanic white . .1 . 0. reerence .0 .0 . 0. reerenc

Non-Hispanic A Am . . . 1.1 1.0 0. 1.1 0.0 . .1 .1 1. 1. 1

Other . . . 0.* 1. 1.0 1.1 0.00 .1 .1 .0 0.* 1.0 0

Sel-reported DM . 1. 1. . .1 .0 .0 0.000 . 11. 1.0 . 1. 1

Sel-reported HTN .1 .0 1. 1. 1. 1. 1. 0.000 . . 1. .1 1. 1

Sel-reported CVD . . . . .00 1.1 . 0.000 1.* 10. . . . 1

Current smoker . . . 0. 1.0 0. 1. 0. . . . 0.* 1. 1

Obese (BMI 0) . . .0 0. 1.0 0. 1. 0.1 . .1 .0 0. 1.1 0

COPD . . . 0. 0. 0. 1.11 0. . . .1 1.1* 1.0 0

Hepatitis C .1 . . 0.* 1.1 0. 1. 0.11 1.* 0.* .* 1.* 1. 0

All . .1 . 0. .0 . . 0.

Prevalence & odds o CKD


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C cKd , (; V O, T 3.)Medicare patients age 65 & older; MarketScan & Ingenix i3 patients age 2064.

Medicare (age 65+) MarketScan (2064) Ingenix i3 (2064)

1999 2001 2003 2005 2007 2001 2003 2005 2007 2001 2003

Diabetes .1 . . . . . . . . .1 .

Hypertension . .1 . . 0. . .1 . 1.0 0. .

CVD . . . .1 .0 . .1 . 1. . 0.

ASHD . . . . . 1.1 1. 1. 1. 1. 1.1

PVD . . . . . 11. 11. 11. . . .

COPD . .1 . . . . .1 .1 .0 . .1

GI 1.0 1.1 11.0 10.1 .1 . .0 .0 .0 . .

CVA/TIA 1. 1.0 0. 0. 0.0 . .0 . .1 .0 .

Dysrhythmia . . . . . . 10. 10. .1 . .

Cancer 0. 1. 1. 1. 1. 1. 1. 1. 1. 1.0 1.1

Anemia 0. 1. . .1 .1 1.1 1. 1.1 1. 1.0 1.

Liver disease . .1 . . . . . . . . .

Hospital days 11.1 10. . . . . . . . . .1Hospital admissions 1. 1. 1. 1. 1. 0. 0. 0. 0. 0. 0.

CKD patient comorbidity


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5pg 12

G v cKd (%) M , , 2007 (V O, F 3.3)Medicare patients age 65 & older, alive on December 31, 2007.

G v (%v M , 2007 (V Period prevalent Medicare patients age 65 & older, alive o

Geographic variations in CKD

3.2 3.6 3.8 4.2 4.4 4.5 5.5 6.2 6.7 7.5 7.9


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eGFR(ml/min/1.7

3m

2)

0

20

40

60

80

100

Non CKD

CKD

585

585.1

585.2

585.3

585.4

585.5

585.9

250.4

403.X1 1995 1997 1999 2001 2003 20

Percentofpatients

0

2

4

6

8

10

Incidence: white

Incidence: Af Am

Prevalence: white

Prevalence: Af Am

E gr (mdrd ) cKdf , 2007 (V O, F 3.19)Prevalent Ingenix i3 patients age 2064, 2007.Error bars represent 25th & 75th percentiles.

T cKd v, f icd-9 , (V O, F 3Point prevalent Medicare patients, age 65 & older, without CKD iprior year & without ESRD (incidence), or without ESRD (prevale

Identifcation o CKD


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Cholesterollevel(mg/dl)

0

50

100

150

200

250

300Total cholesterol (mg/dl)

LDL cholesterol (mg/dl)

All CKD CKD/DM

CKD/no DM

CKD/CVD CKD/no CVD

CKD/DM/CVD

A1c(%)

0

5

10

15

DM + CKD DM + CKD + CVD

Insulin

Sulfonylureas

Thiazolidinediones (TZDs)

5pg 14

M ldl cKd k , 2007 (V O, F 4.23)Ingenix i3 CKD pts 5064, surviving all o 2007. 25th/75th percentiles:box edges; median: line in box; 10th/90th percentiles: error bars.

M A1 v () cKd , 2007 (V O, F 4Ingenix i3 diabetic CKD patients age 5064, surviving all percentiles: box edges; median: line in box; 10 th/90th perc

Biochemical levels & drug therapy in CKD patients


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All CKD CKD/DM

CKD/no DM

CKD/CVD CKD/no CVD

CKD/DM/CVD

P

ercentwithcholesterolcontrolled

0

25

50

75

100Total cholesterol (


16/32

All HTN CVD COPD

Admissionsper1,0

00patientyears

0

300

600

900

1,200

1,500

1,800

All HTN CVD

detsujdAdetsujdanU

Non-CKD

Stage 1

Stage 2

Stage 3

Stages 4-5

5pg 16

Uj j - z M , cKd , 2007 (V O, F 5.2)Point prevalent Medicare patients age 66 & older.

Hospitalization in CKD patients


17/32

Relative

risk

0

1

2

3

4

5

2003

2005

2007

No CKD, DM,

or CVD

DM only

(non-CKD,

non-CVD)

CKD + DM DM + CVDCKD only

(NDM, non-

CVD)

CVD only

(non-CKD,

NDM)

CKD + CVD

Rv k M 66 , -k (V O, F 5.22)Point prevalent Medicare patients age 66 & older.

Mortality risk in CKD patients


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Months after AKI discharge

1 2 3 4 5 6

Percentofpatients

0

10

20

30

401 visit

2-4 visits

At least 1 visit

1 2 3 4

All AKI AKI & dialysis

5pg 18

V z k j, 2006 (V O, F 8.13)Prevalent Medicare AKI patients age 65 & older, 2006.

Acute kidney injury: care ater hospital discharge


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1 2 3 4 5 6 7 8 9 10 11 120.0

0.2

0.4

0.6

0.8

1.0

Nephrologist: all AKI

Nephrologist: AKI & dialysis

No nephrologist: all AKI

No nephrologist: AKI & dialysisCumulativeprobabilityoftestin

g


1 2 3 4 5 6 7 8 9 10

Cumulativeprobabilityoftestin

g

0.0

0.1

0.2

0.3

0.4

0.5

Nephrologist: all AKI

Nephrologist: AKI & dialysis

No nephrologist: all AKINo nephrologist: AKI & dialysis

P z aKi, 2006 (V O, F 8.14)Prevalent Medicare AKI patients age 65 & older, 2006.

P aKi, 2006 (V O, F 8.15)Prevalent Medicare AKI patients age 65 & older, 2006.


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-8Q -7Q -6Q -5Q -4Q -3Q -2Q -1Q

Percentofpatients

0

20

40

60

80

100

Medicare (67+): CKD claims

Medicare: nephrologist visits

MarketScan (all ages): CKD claims

MarketScan: nephrologist visits

Ingenix i3 (all ages): CKD claims

Ingenix i3: nephrologist visits

Quarter prior to ESRD Quarter prior to ESRD

-8Q -7Q -6Q -5Q -4Q -3

Percentofpatients

0

10

20

30

40

50

60

70

80Creatinine

Lipid

A1c

5pg 20

cKd v esrd, , 2007 (V O, F 7.2 7.4)Incident ESRD patients, 2007.

R , , A1 esrd, 2007 (V O, F 7.7, 7.10Incident Medicare ESRD patients age 67 & older, 2007.

Patient care & vascular access in the transition to ESRD


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-12 -10 -8 -6 -4 -2 1 3

Rateper100patientmonth

s

0

20

40

60

80

100

120

Medicare (age 67+)

MarketScan (all)

Ingenix i3 (all)

Catheters Fistulas Grafts

-12 -10 -8 -6 -4 -2 1 30

5

10

15

20

25

-12 -10 -8 -6 -4 0

2

4

6

8

10

R esrd, , 2006 (V O, F 7.2426)Medicare: incident hemodialysis patients age 67 & older, 2006. MarketScan & Ingenix i3: all dialysis patients, 2006.


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Months pre- & post-initiation

-6 -5 -4 -3 -2 -1 1 2 3 4 5 6

PPPMe

xpenditures(dollars,

intho

usands)

0

10

20

30

40

Medicare

(age 67+)

MarketScan(age


23/32

80 84 88 92 96 00 04

Numberofpatients(inthousan

ds)

0

30

60

90

120

HD (2007: 101,688)

PD (6,506)

Tx (2,665)All (110,859)

Incident counts

80 84 88 92 96 00

Ratepermillionpopulation

0

100

200

300

400

HD (2007: 325)

PD (21)

Tx (8.1)All (354)

Incident rates

I j , (V T, F .4)Incident ESRD patients; excludes those with unknown modality.

ESRD incidence


24/32

80 84 88 92 96 00 04

Numberofpatients(inthousa

nds)

0

100

200

300

400

500

600

HD (2007: 341,264)

PD (26,340)

Tx (158,739)

All (526,343)

Prevalent counts

80 84 88 92 96

Ratepermillionpopulation

0

400

800

1,200

1,600

2,000

HD (2007: 1,076)

PD (84)

Tx (502)All (1,665)

Prevalent rates

5pg 24

ESRD prevalence

Pv j , (V T, F .5)December 31 point prevalent ESRD patients; excludes those with unknown modality.


25/32

80 84 88 92 96 00 04 08 12 16 20

Numberofpatients(inthou

sands)

0

40

80

120

160

80 84 88 92 96 00 04 08 10

200

400

600

800Incident Prevalent

2005 JASN paper: 136,166 (2015)

2008 ADR: 150,772 (2020)

New projection: 142,858 (2020)Actual: 110,996 (2007)

2005 JASN paper: 712,290 (2015)

2008 ADR: 784,613 (2020)

New projection: 774,386 (2020)Actual: 527,282 (2007)

Pj v esrd 2020 (V T, F 2.1)Counts projected using a Markov model. See the complete ADR at www.usrds.org or detailed analytical methods.

ESRD projections to


26/32

ESRDincident

rates (permillionpop.)

354(2007

actual)

Deathsfrom CV

disease(per

1,000 ptyears

at risk)

Fistulause

(% ofincident

HDpatients)

% of ptson tx

wait-list

% of ptsreceiving

transplantwithin 3years of

ESRD

Incidentrate

due toDM (permillionpop.)

221(2010

target)

68.1(2007

actual)

62.1(2010

target)

50%(2010

target)

41.1%(2006

actual)

30%(2010

target)

17.1%(2006

actual)

155(2006

actual)

90(2010

target)

30.5%(2010

target)

17.9%(2004

actual)

% CKD ptsreceiving

compre-hensiveDM

monitoring

% ptsreceiving

ACE-Is/ARBs

Compre-hensive

pre-ESRDcoun-seling

60%(2010

target)

9.6%(2007

actual)

36%(2010

target)

33.8%(2007

actual)

66.6%(2005

actual)

14%(2010

target)

% ptsreceivin

urinarymicroabumintesting

33.6%(2007

actual

5pg 26

H P 2010 v v (V T, F .1)See the complete ADR at www.usrds.org or detailed analytical methods.

Clinical care o ESRD patients


27/32

Months after initiation

Deathsper1,0

00patientyearsatrisk

0

100

200

300

400

500

2 3 4 5 6 7 8 9 10 11 12

All-cause 96

All-cause 06

Infection 96

Infection 06

Cardiovascular 96

Cardiovascular 06

80 84 88 92 96 00150

200

250

300

350

1st year

2nd year

3rd year

4th year

5th year

D

eathsper1,0


Aj - -f f (V T, F 1.1)Incident hemodialysis patients.

Aj (V T, F 6.1)Incident hemodialysis patients.

Mortality rates in incident dialysis patients

H i l d i i i i


28/32

93 95 97 99 01 0

Admissionsper1,0

00patientyears

0

50

100

150

200

Peritoneal dialysis:peritonitis

Hemodialysis:vasular access infectio

91 93 95 97 99 01 03 05

Adm

issionsper1,0


0

200

400

600

800

1,000

10-


29/32

94 96 98 00 02 04

Percentofpatientswithculture

0

10

20

30

40

50

60

Blood culture

Other culture

Both

Any culture

91 94 97 00 03 06

Placementspre1,0

00ptyears

atrisk

300

400

500

600

700

Diabetic

Non-diabetic

All

Vascular access placement; bacterial cultures

B (V T, F 1.13)Point prevalent hemodialysis patients who survive the entire ye

C v , (V T, F .13)Period prevalent hemodialysis patients.

Kid t l t ti


30/32

91 95 99 03 07

RateofESRDpermillionpopulation

0

100

200

300

400

500

Transplantrateper100ESRDp

tyrs

0

2

4

6

8

10

Incident rate

Transplant rate

Incident & transplant rates, unadj. alpsnartlatoTtsiltiawyendiK

Kidneywaitlistcounts(in1,000s)

Medianwaittime(years)

91 95

Transplants(in1,000s)

0

5

10

15

20

Counts: first listings

Counts: prior txs

Median waittime: firstlistings

Median waittime: prior txs

0

10

20

30

40

50

60

70

0

1

2

3

4

5

6

7

88 92 96 00 04

5pg 30

T : j , , (V T, F 7.1)Patients age 20 & older. See the complete ADR atwww.usrds.org or detailed analytical methods.

Kidney transplantation

C t ESRD


31/32

91 92 93 94 95 96 97 98 99 00 01 02 03 04 05 06 07

Totalexpenditures($,

inb

illions)

0

5

10

15

20

25

Inpatient

Outpatient

Physician/supplierSkilled nursing

Home health

Hospice

92 94 96 98 00 02

Medicarespending($,

inbillio

ns)

0

1

2

3Other injectables

IV iron

IV vitamin D hormone

ESAs

T M esrd, v (V T, F 11.5)See the complete ADR at www.usrds.org or detailed analytical methods.

T M j (V T, F 11.13)Period prevalent dialysis patients.

Costs o ESRD


32/32

United States RenalData System

national institutes o healthnational institute o diabetes

& digestie & Kidney diseasesdiision o Kidney, urologic,

& hematologic diseases

This report of the United States Renal Data System is produced by the USRDS

Coordinating Center, operated under NIH contract HHSN 267 2007 15002C /

NO1-DK-7-5002 by the Minneapolis Medical Research Foundation.

us renal data systemrds_booklet_2009

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