Lead Agency:		National Institutes of Health

[Note: The National Library of Medicine has provided PubMed links to available references that appear at the end of this focus area document.]

Contents

GoalPage 4-3

Overview. Page 4-3

Issues and Trends. Page 4-3

Disparities. Page 4-5

Opportunities. Page 4-7

Interim Progress Toward Year 2000 Objectives. Page 4-8

Healthy People 2010—Summary of Objectives. Page 4-9

Healthy People 2010 Objectives. Page 4-10

Related Objectives From Other Focus Areas. Page 4-20

Terminology. Page 4-23

References. Page 4-25

Goal

Reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs.

Overview

Issues and Trends

Chronic kidney failure is the most significant result of chronic kidney disease. When kidney function has deteriorated and is no longer adequate to sustain life and the process is considered irreversible, renal replacement therapy (RRT)—dialysis or transplantation—becomes necessary to maintain life. Treated chronic kidney failure, also called end-stage renal disease (ESRD), is the most feared consequence of kidney disease. Chronic renal insufficiency, however, is more common than treated chronic kidney failure and can also severely affect health and well-being. Therefore, ideally, programs should be directed at preventing the development of chronic renal insufficiency and its subsequent progression to ESRD.

Unfortunately, chronic renal insufficiency is usually asymptomatic, and the exact number of people affected is unknown. The best available estimates are based on national surveys. Current estimates indicate approximately 10 million persons aged 12 years and older have some form of chronic kidney disease.[1] People with end-stage kidney failure represent a small fraction of all individuals with chronic kidney disease. A significant proportion of people with chronic kidney failure progress to end stage. The challenge is to initiate effective programs to prevent progression of established kidney disease and to institute methods to assess the progress of such initiatives.

In 1997, 80,248 new cases of end-stage kidney failure were reported.[2] Virtually all of these patients became permanently dependent on renal replacement therapy to stay alive.

Dialysis and kidney transplantation are the two methods of treatment available to people with kidney disease when they reach end stage. In 1997, 361,031 people in the United States depended on either dialysis or transplants to replace the function of their own failed kidneys.[3] Although these treatments are lifesaving, dialysis and transplants have substantial limitations. Neither treatment restores normal health, and both are expensive.[4] The rates of illness, disability, and death experienced by individuals with treated chronic kidney failure are substantially higher than those of the general population.[5]

In most instances, terminal kidney failure develops as the result of progressive damage to the kidneys over a decade or more. A number of underlying diseases can cause progressive kidney failure. The two most important of these are diabetes, which in 1997 accounted for 42 percent of the new cases of chronic kidney failure, and high blood pressure, which was responsible for 26 percent of the new cases.[6] Other conditions that contribute significantly include glomerulonephritis, vasculitis, interstitial nephritis, and genetic and congenital disorders, particularly polycystic kidney disease.[7]

Chronic kidney failure affects people of all ages. The number of new cases peaks in the sixth decade of life, but 25 percent of persons arriving at end stage in 1997 were under age 45 years, and 1.5 percent—nearly 1,100—were under age 20 years.6 Kidney failure is particularly devastating in childhood, often resulting in impaired growth and development.

A worrisome increase in the number of new cases of kidney failure occurred between 1987 and 1997. The rate increased from 142 per million population in 1987 to 296 per million population in 1997,[8] representing an increase in the annual number of new cases from 34,797 to 80,248,[9] respectively.

This relentless growth in new cases of kidney failure has occurred in spite of the fact that death rates from other diseases, especially cardiovascular diseases, have declined.[10] The increase has not been confined to a single age group. Although the rates of new cases have grown slightly more rapidly for individuals aged 75 years and older, sizable increases have been noted in every age group.[11]

The causes of these increases are not completely understood, but one major factor appears to be an increase in the number of new cases of diabetes, particularly type 2 diabetes.[12], [13] In 1987, the rate of new cases of treated chronic kidney failure due to diabetes was 45 per million population. By 1997, the rate had increased to 124 per million population.[14]

Treatment for end-stage kidney failure has a substantial impact on Federal resources for health care. The 1972 Social Security Amendment (Public Law 92-603) instituted federally financed health care coverage for dialysis and renal transplantation, effective July 1, 1973. The cost of this program has far exceeded original expectations. Medicare spending in 1996 was estimated to be $10.96 billion, a 12.5 percent increase from the $9.74 billion spent in 1995. The total expenditure by all payers for treating these patients in 1996 was estimated at $14.55 billion, up from $13.05 billion in 1995.[15] Although this patient population made up only 0.6 percent of the total Medicare population in 1994, it consumed 5.1 percent of Medicare expenditures.[16] The increases in the cost per patient have been modest, but the driving force behind the growth in these expenditures has been the growing number of patients.

Kidney disease develops and progresses more rapidly to end stage in people with chronic health problems (such as type 1 or type 2 diabetes or high blood pressure) or with a family history of genetic kidney diseases. Therefore, people with these chronic health problems require counseling about the possibility of kidney disease and the steps they must take to avoid serious kidney complications. Also, people who have proteinuria and/or elevated serum creatinine have a greater likelihood of developing serious cardiovascular disease (CVD) complications. Therefore, cardiovascular risk assessment and management should include kidney function to prevent the consequences of kidney failure. Because national data systems will not be available in the first half of the decade to track progress, these issues are not addressed in the chapter.

Disparities

Kidney disease has a disproportionate impact on certain racial and ethnic groups, especially African Americans and American Indians or Alaska Natives. African Americans have the highest overall risk of chronic kidney disease. The reasons are not entirely explained by the higher number of persons in this population who have diabetes and high blood pressure.[17], [18] On average, African Americans develop end-stage kidney failure at an earlier age than whites (55.8 years compared to 62.2 years).[19] American Indians or Alaska Natives have a much higher risk of chronic kidney disease due to diabetes than whites. Overall, the rates of new cases are 4 times higher in African Americans and American Indians or Alaska Natives and 1.5 times higher in Asians or Pacific Islanders than in whites.

Annual increases in ESRD rates are greater in certain racial and ethnic populations than in white populations. Rates of new cases are increasing by 7 percent per year for African Americans, 10 percent per year for American Indians or Alaska Natives, and 11 percent for Asians or Pacific Islanders, compared to 6 percent per year for whites. Two communities of an American Indian Tribe, the Zuni Pueblo in New Mexico and in Sacaton, Arizona, may have the highest rates of chronic kidney failure in the world, at 12.6 and 14.0 times the overall average U.S. rate, respectively. Projections indicate that increases in the rates of new cases will continue in American Indians or Alaska Natives.

Although complete data are not yet available, some evidence indicates that persons of Mexican ancestry also may have a high risk of developing chronic kidney failure, particularly due to diabetes.[20], [21] In 1995, the Health Care Financing Administration changed the way in which data on race and ethnicity are collected on the Medical Evidence Form used to enroll patients into the Medicare End-Stage Renal Disease Program. Data from 1997 suggest that 7 percent of the ESRD patients are of Mexican ancestry and another 4 percent are of Hispanic ancestry from areas other than Mexico.[22]

The disproportionately high rates of chronic kidney failure among certain racial and ethnic groups have resulted in a greater burden of disease in these communities. In 1996, African Americans constituted 12.6 percent of the U.S. population but 29.8 percent of ESRD patients; American Indians or Alaska Natives constituted 0.9 percent of the U.S. population but 1.7 percent of those receiving renal replacement therapy.[23] On December 31, 1996, the point-prevalent rate per million population (adjusted for age and gender) was 3,404 in African Americans and 2,761 in American Indians or Alaska Natives, compared to 754 in whites, differences of 4.5- and 3.7-fold, respectively.[24] Data on persons of Asian or Pacific Islander ancestry indicate slightly higher incidence and prevalence rates than those for whites.[25]

There is a slight preponderance of kidney failure in men. In 1997, the incidence of treated chronic kidney failure was 322 per million population in men, compared with 271 per million in women.8

Renal transplantation is an important lifesaving renal replacement therapy and has been shown to offer many advantages when compared with dialysis.[26], [27] In 1997, 12,445 transplants were performed in the United States. There was significant gender discrepancy, with 7,352 transplants for men, compared with 4,948 for women.[28] Racial and ethnic disparities also exist. Between 1994 and 1997, the first cadaveric transplantation rates (per 100 patient years) in the pediatric age group were 31 for black males, 28 for white males, 19 for black females, and 26 for white females. For recipients between the ages of 20 and 44 years, the rates were 7 for black males, 17 for white males, 7 for black females, and 15 for white females. In the 45- to 65-year age group, the rates were 4 for black males, 8 for white males, 2 for black females, and 6 for white females.[29] The data from the U.S. Renal Data System (USRDS) database also confirm that the transplantation rate is lower for Native Americans. The transplantation rate in Asians is equivalent to the rate in whites.[30] Reasons for the racial and ethnic disparities in the rate of transplantation are varied and include differences in finding human leukocyte antigen matches, cultural attitudes and beliefs on the part of both patients and health care providers, socioeconomic status, rates of organ donation, and geographic location.

Opportunities

Major risk factors for the development and progression of chronic kidney disease include diabetes, high blood pressure, environmental exposures, proteinuria, family history of kidney disease, and increasing age. African Americans and American Indians or Alaska Natives who have these risk factors are especially susceptible to the development of chronic and progressive kidney disease.[31], [32] Strategies for preventing the development of chronic kidney disease, therefore, should use appropriate methods to target these populations.

Under certain circumstances, the progression of kidney disease to end stage can be slowed or halted. Three interventions are effective in certain defined populations: glycemic control (for patients with diabetes), blood pressure control (for patients with high blood pressure), and use of angiotensin-converting enzyme (ACE) inhibitors. Interventions to slow the progression of kidney disease and prevent chronic kidney failure are likely to have the greatest impact if applied early in the course of the disease. Unfortunately, because kidney disease in its early stages is generally asymptomatic, many people who would benefit from these interventions are not identified. Early identification of patients at risk for chronic kidney disease is essential in reducing the growth in the number of new cases of treated chronic kidney failure. For example, microalbuminuria screening and more intensive treatment of patients with microalbuminuria are an important part of a strategy to reduce nephropathy in persons with type 1 diabetes, both in terms of economic indices and clinical outcomes.[33], [34], [35] This strategy also may be useful in type 2 diabetes.

Patient care must continue to emphasize interventions to conserve residual renal function. At a certain stage, however, providing appropriate preparation for renal replacement therapy becomes advisable. Several studies show that many patients with chronic kidney failure do not receive optimum preparation for treated chronic kidney failure in the year prior to the commencement of RRT. This lack of optimal preparation has a substantial effect on the cost of care and on illness and disability at the time of RRT.[36]

Kidney transplantation has emerged as the preferred therapy for many patients with treated chronic kidney failure, particularly children. Kidney transplantation confers a survival advantage over dialysis.[37] Over the past decade, transplantation success rates, especially 1-year patient and graft survival, have improved steadily. This improvement has been observed in both cadaveric and living-related transplants.[38], [39] For young children, kidney transplantation results in improved rates of growth.[40] Because of accumulating evidence on the advantages of transplantation, equal access of all population groups to transplantation is a substantial concern. Certain racial and ethnic groups and women consistently have longer waiting times and lower rates of kidney transplantation than white males.[41], [42], [43], [44], [45], [46]

Attention to risk factors for kidney disease and interventions to slow its progression are urgently needed. This need is driven by the increasing number of cases of treated chronic kidney failure, its disproportionate effect on certain racial and ethnic groups, the high societal cost of the disease, and the impact on Federal health care resources.

Interim Progress Toward Year 2000 Objectives

Healthy People 2000 did not include a chapter on chronic kidney disease. However, objectives relating to chronic kidney disease were included in several chapters. Since the mid-1980s, the number of new cases of ESRD has grown steadily. One objective concerning diabetes addressed ESRD. Results show that ESRD among people with diabetes has more than doubled since 1987 and is moving away from the target. Subobjectives tracking ESRD due to diabetes among African Americans and American Indians or Alaska Natives also are moving away from their targets.

Note: Unless otherwise noted, data are from the Centers for Disease Control and Prevention, National Center for Health Statistics, Healthy People 2000 Review, 1998–99.

Healthy People 2010—Summary of Objectives

Chronic Kidney Disease

Goal: Reduce new cases of chronic kidney disease and its complications, disability, death, and economic costs.

Number	Objective Short Title
4-1	End-stage renal disease
4-2	Cardiovascular disease deaths in persons with chronic kidney failure
4-3	Counseling for chronic kidney failure care
4-4	Use of arteriovenous fistulas
4-5	Registration for kidney transplantation
4-6	Waiting time for kidney transplantation
4-7	Kidney failure due to diabetes
4-8	Medical therapy for persons with diabetes and proteinuria

 

Healthy People 2010 Objectives

4-1.		Reduce the rate of new cases of end-stage renal disease (ESRD).

Target: 217 new cases per million population.

Baseline: 289 new cases of end-stage renal disease per million population were reported in 1997.

Target setting method: Better than the best.

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

The current average annual increase in new cases of treated chronic kidney failure rates is 6 percent. Therefore, the expected rate in 2010 would be 612 new cases per million population. Without improvements in prevention and because of changes in demographics and increases in the number of cases of diabetes, rates of new cases of treated chronic kidney failure are expected to continue to rise 5 to 8 percent per year.

4-2.		Reduce deaths from cardiovascular disease in persons with chronic kidney failure.

Target: 52 deaths per 1,000 patient years at risk.

Baseline: 70 deaths from cardiovascular disease per 1,000 patient years at risk (in persons with ESRD) occurred in 1997.

Target setting method: Better than the best.

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Cardiovascular disease is the major cause of death among patients with chronic renal failure and ESRD. Therefore, targeting reduction in CVD deaths will lead to a significant decrease in deaths for this population. The increased risk of CVD in kidney disease patients is evident before the onset of terminal kidney failure. Increases in the number of CVD deaths also are seen in individuals with proteinuria or elevated creatinine (both are markers of declining kidney function). CVD death rates in the treated chronic kidney failure population are estimated to be 30-fold higher than in the general population.[47] The known risk factors for CVD in the general population include age, male gender, diabetes, elevated cholesterol, high blood pressure, smoking, and family history. Elevated homocysteine levels in the blood also may be an important risk factor in treated chronic kidney failure patients and at earlier stages in the progression of kidney disease.[48], [49], [50] Strategies to reduce CVD deaths should target risk reduction before terminal kidney failure.[51] All responsible health care providers can initiate the strategies to reduce CVD deaths as suggested in published guidelines.51

4-3.		Increase the proportion of treated chronic kidney failure patients who have received counseling on nutrition, treatment choices, and cardiovascular care 12 months before the start of renal replacement therapy.

Target: 60 percent.

Baseline: 45 percent of newly diagnosed patients with treated chronic kidney failure received counseling on nutrition, treatment choices, and cardiovascular care in 1996.

Target setting method: 33 percent improvement. (Better than the best will be used when data are available.)

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Medically appropriate care of kidney disease patients within 12 months before the start of renal replacement therapy reduces the substantial illness, disability, and death associated with treated chronic kidney failure.[52] Appropriate preparation for RRT includes reduction in CVD risk factors, treatment of anemia, optimum therapy to preserve residual renal function, consultation about nutrition, and patient education about RRT methods. Patients should be seen by a specialist in RRT at least 12 months prior to initiation of RRT for general counseling. However, specific issues—such as vascular access and estimation of residual renal function—need to be addressed at least 6 months prior to RRT. Many patients with chronic renal failure are not seen by health care professionals who have RRT expertise until very near the time that RRT will be required. In a USRDS survey of 3,468 new dialysis patients, 55 percent had not been seen by a nephrologist 1 year prior to the start of RRT, and 33 percent had not been seen even 3 months before RRT.[53] Although control of diet is a major aspect of care for patients with chronic kidney failure and terminal kidney failure, by the start of RRT, 46 percent of the patients had not seen a dietitian.

4-4.		Increase the proportion of new hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access.

Target: 50 percent.

Baseline: 29 percentof newly diagnosed patients with treated chronic kidney failure on hemodialysis used arteriovenous fistulas as the primary mode of vascular access in 1997.

Target setting method: 72 percent improvement (consistent with Dialysis outcomes quality initiative [doqi] guidelines). (better than the best will be used when data are available.)

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Patients receiving renal replacement therapy as of December 31, 1997, were treated predominantly (72 percent) with dialysis. Of these, 88 percent were on hemodialysis. Vascular access is the major lifeline for hemodialysis patients. The presence of a functioning vascular access site represents a critical factor in the well-being of these patients. Unfortunately, however, it also is the largest single cause of illness and disability in patients receiving hemodialysis for renal replacement therapy, accounting for nearly 25 percent of all hospitalizations. Complications and problems related to vascular access have been estimated to account for as much as 17 percent of the health care costs associated with treated chronic kidney failure.[54]

Monitoring the type of vascular access for dialysis in new patients is an important method to assess the adequacy of preparation for RRT. Clinical evidence shows that patients with endogenous arteriovenous fistulas experience lower complication rates than patients with synthetic grafts. In the United States, the use rate for arteriovenous fistulas is under 30 percent.[55] Arteriovenous fistulas, ideally, should be placed at least 6 months before the start of dialysis. Early placement of arteriovenous fistulas is particularly important for elderly persons, becauseatheroscleroticvessels may take a much longer time to dilate to a usable diameter.

4-5.		Increase the proportion of dialysis patients registered on the waiting list for transplantation.

Target: 66 percent of dialysis patients.

Baseline: 20 percent of newly diagnosed treated chronic kidney failure patients under age 70 years were registered on the waiting list in 1994–96.

Target setting method: Better than the best.

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.

DNA = Data have not been analyzed. DNC = Data are not collected. DSU = Data are statistically unreliable.

Successful renal transplantation confers many advantages, including improvements in physical and psychological growth in children and improved survival and quality of life for recipients in general. The prospects of receiving a kidney transplant, however, are determined by a number of factors. These factors include age, primary cause of kidney failure, race and ethnic origin, gender, geographic location, and availability of suitable donors. Any combination of these factors may directly influence the first important step in the process of receiving a kidney transplant—namely, being registered on the waiting list. Significant disparities exist in the people who are registered on the waiting list. Women and people from certain racial and ethnic groups—particularly, African Americans—are less likely than other kidney transplant candidates to be registered on the waiting list.40, 55, [56]

4-6.		Increase the proportion of patients with treated chronic kidney failure who receive a transplant within 3 years of registration on the waiting list.

Target: 51 registrants per 1,000 patient years at risk.

Baseline: 41 registrants per 1,000 patient years at risk (since placed on dialysis) received a transplant within 3 years in 1995–97.

Target setting method: Better than the best.

Data source: U.S. Renal Data System (USRDS), NIH, NIDDK.