2018 USRDS Annual Data Report: Executive Summary

2018 USRDS ANNUAL DATA REPORT vii

2018 USRDS Annual Data Report:

Executive Summary

Introduction

This year marks the publication of the 29th Annual

Data Report (ADR) of the United States Renal Data

System (USRDS). Broadly, the mission of the USRDS is

to characterize the kidney disease population in the

country and serve as a comprehensive, regularly

updated, online resource for descriptive epidemiology

of kidney disease in the United States. In addition,

supporting investigator initiated research by data

provisioning to the community of researchers is one of

the key functions of the USRDS. To this end, the

USRDS prepares and regularly updates the standard

analysis files (SAFs) for researchers, and fulfills data

merge requests from researchers or organizations

seeking to examine the outcomes of populations of

interest with respect to the occurrence of end-stage

renal disease (ESRD) and related complications. Last

but not least, the USRDS Coordinating Center staff

responds to a variety of queries related to kidney

disease, ranging from simple to complex, from

individuals as well as governmental and non-

governmental agencies.

Federal agencies have done much to raise awareness

of kidney disease as a significant public health problem.

Only few decades ago kidney failure was a fatal disease.

When dialysis was developed and made available as a

chronic therapy, lack of insurance coverage represented

a barrier to treatment. This resulted in the passage of

the landmark Medicare ESRD program in 1972 to fund

ESRD care for all Americans.

In 1988, the National Institute of Diabetes and

Digestive and Kidney Diseases (NIDDK) established the

USRDS, the largest and most comprehensive national,

ESRD and chronic kidney disease (CKD) surveillance

system. The initial USRDS ADRs offered a detailed

descriptive epidemiology of ESRD alone. A chapter

addressing CKD was introduced in 2003, and was

subsequently expanded into a multi-chapter CKD

volume from 2008 onward.

Since 2000, CKD has received increasing attention.

The consensus definition and staging classification of

CKD / KDOQI Clinical Practice Guidelines for Chronic

Kidney Disease: Evaluation, Classification, and

Stratification were first published in 2002. That year

also marked the launch of NIDDK’s National Kidney

Disease Education Program (NKDEP). NKDEP provides

information for patients and providers regarding the

detection of CKD and care of people with the disease.

In 2006, the Centers for Disease Control and

Prevention launched a broad CKD initiative, with the

CDC CKD Surveillance System as its major component.

This project prioritizes the earlier stages of CKD, as

opposed to ESRD, or the late transitions of care from

advanced stages of CKD to ESRD.

In the 2018 ADR, we continue to characterize the

spectrum of CKD and ESRD patient populations, and

describe the distributions of patients by attributes such

as age, sex, race, and comorbid conditions. The topic of

Acute Kidney Injury (AKI) continues to receive

attention, by virtue of both its bidirectional

relationship with CKD and recent policy changes that

now provide reimbursement to outpatient dialysis units

for AKI patients who are dialysis dependent.

The two current USRDS special studies investigate

the transition of care from CKD to ESRD and end-of-

life care for those with advanced kidney disease. These

studies continue to contribute valuable findings to

guide practice and policy in the renal community.

Our primary audiences are healthcare providers

involved in care of patients with kidney disease —

nephrologists, transplantation specialists, and general

physicians. This report is also of value for healthcare

facilities and organizations that provide comprehensive

kidney care and renal replacement therapies, and to

researchers, policy makers, and service or charitable

organizations. We dedicate this work to the individual

2018 USRDS ANNUAL DATA REPORT

viii

patients and their families and caregivers whose daily

lives are affected by kidney disease.

What’s New (or Relatively New) in the 2018

USRDS Annual Data Report

Beginning on October 1, 2015, the newly revised

International Classification of Diseases, Tenth

Revision, Clinical Modification (ICD-10-CM) coding

system was implemented. Many of our data sources

utilize these diagnosis codes to identify specific stages

of kidney disease and common comorbid conditions.

We continue to build on the challenge of transitioning

our data and analyses from ICD-9-CM diagnosis and

procedure codes to the ICD-10-CM codes. This has

allowed us to provide continuity with the data trends

and analyses presented in previous ADRs. Our CKD

and ESRD Analytical Methods chapters include

detailed comparisons of the ICD-9-CM and ICD-10-

CM diagnosis codes used to define medical conditions

in the health insurance claim data files throughout the

ADR.

No individual data source exists that captures the

disease experiences of all Americans who live with

kidney disease. A large proportion of our information

is drawn from Medicare beneficiaries; however, they

are not a nationally representative population.

Since 2017 we have included two new data sources

that have expanded our coverage of the U.S.

population.

 We continue to examine data purchased from the

Optum Clinformatics™ Data Mart Database

(OptumInsight, Eden Prairie, MN). The Optum

Clinformatics™ Data Mart provides paid medical

and prescription claims and enrollment

information for participants in commercial

insurance plans (e.g. HMOs), and the Medicare

Advantage plans of a large U.S. managed care

health insurance company. Included are plan

members who were enrolled in both a medical and

a prescription plan. These data allow us to

examine the experience of younger, employed

individuals, and all areas of the country are

represented in the samples. The Optum

Clinformatics™ cohorts include information on

about nine million lives per year.

 We continue to expand our analyses of Veterans

Health Administration Data (VHA). This national

health system-derived data represents more than

six million veterans.

As in the 2017 ADR, in the interest of drawing

attention to disparities whenever possible, we

continue to characterize the ESRD population by race

and ethnicity categories, as opposed to race or

ethnicity. In previous ADRs, we considered ethnicity

separately from race, based on whether a person was

Hispanic, or not. As the Hispanic population in

America grows, it becomes more meaningful and

accurate to examine separate cohorts of non-Hispanic

White, non-Hispanic Black, and Hispanic patients, the

majority of whom identify themselves as White.

Whenever possible, our race categories match those of

the U.S. Census. Census definitions change

periodically, most recently in 2000. We report data

prior to 2000, but in the 2018 ADR employ the most

recent census categories wherever possible. However,

race and ethnicity categorizations are limited by the

categorizations available in the source datasets. We

were unable to replicate the current census race and

ethnicity characterization in the CKD volume for this

reason.

In the interest of examining regional differences,

and to provide information salient to our audiences in

different areas of the country, we continue to report

geographic variations by health service area or ESRD

network.

A new chapter on CKD in children and adolescents

has been included in 2018, along with continued

expanded coverage of ESRD among children,

adolescents and young adults, including information

about childhood onset ESRD among patients who

have transitioned to adulthood. The ESRD

hospitalization chapter now includes emergency

department visits and observation stays in addition to

the continued emphasis on inpatient stays and

readmissions.

DATA SOURCES AND ANALYTICAL METHODS

Originally, the ADR was the product of a stand-

alone ESRD database that served as a source of

descriptive epidemiology of ESRD patients covering

EXECUTIVE SUMMARY

areas such as incidence, prevalence, modality of renal

replacement and treatment history, along with

biochemical data, dialysis claims, and information on

medication use, payer histories, hospitalization

events, deaths, physician/supplier services, dialysis

providers, and renal transplantation. The findings

presented in the ADR are now drawn from numerous

data types and sources. Details of these are described

in the Data Sources sections of the CKD Analytical

Methods and ESRD Analytical Methods chapters. We

also describe data preparation and management,

variable definition, and the analytic methods used to

generate the study cohorts, and produce the statistics,

figures, and tables presented in the ADR.

Downloadable PowerPoint files containing tables

and figures in each chapter are available on the

USRDS website. In addition, readers should be aware

that the underlying data tables used to generate the

figures in individual chapters are available for

download as Microsoft Excel spreadsheets on the

USRDS website. Thus, in order to supplement the

figures presented in the ADR chapters, readers may

opt to examine the data tables in the Excel download

files.

RENAL DATA EXTRACTION AND REFERENCING

(RENDER) SYSTEM

The USRDS Renal Data Extraction and Referencing

(RenDER) System is an online data querying

application available through the USRDS website,

allowing access to a wealth of information regarding

ESRD in the United States. It quickly returns an

accurate table of data or interactive map based upon

the user's query specifications. Tables can then be

copied into a spreadsheet application on the user's

computer for further manipulation and investigation.

Map images can be copied or saved to local

applications. In addition, a dBase file of the data,

which can be opened in MS Excel, is also offered for

download. We are continuing to develop RenDER and

plan to continue enhancing the functionality of the

interface. We plan to eventually add the capability for

additional rate calculations and graphing capabilities,

as well as an expanded database.

SUMMARY OF DATA SOURCES

Data on CKD in the non-institutionalized, general

population come from the National Health and

Nutrition Examination Survey (NHANES) and the

Behavioral Risk Factor Surveillance System (BRFSS),

both conducted by the Centers for Disease Control

and Prevention.

The majority of USRDS analyses employ claims-

based and enrollment data obtained from the Centers

for Medicare & Medicaid Services (CMS). Files for

Medicare Parts A and B contain billing data from final

action claims submitted for Medicare beneficiaries in

which all adjustments have been resolved. The

Medicare Prescription Drug Event File includes data

submitted by health plans whenever a Medicare

beneficiary fills a prescription; Part D coverage data

has been available since its introduction in 2006.

For patients with CKD, acute kidney injury, and

related comorbidities, analyses are performed on the

Medicare 5% sample. These Standard Analytical Files

(SAFs) are a random sample of 5% of the entire

Medicare population. Medicare ESRD Claims SAFs

contain data from claims for medical services provided

to Medicare beneficiaries with ESRD. Institutional

claims include those for inpatient, outpatient, skilled

nursing facility, home health agency, and hospice

services. Non-institutional claims include those for

physicians and suppliers, and for durable medical

equipment.

The Medicare Enrollment Database (EDB) is the

designated repository of all Medicare beneficiary

enrollment and entitlement data, including current

and historical information on beneficiary residence,

Medicare as secondary payer and employer group

health plan status, and Health Insurance

Claim/Beneficiary Identification Code cross-

referencing.

Other CMS data files consist of information

submitted through ESRD specific forms completed by

providers or facilities. These include the Medical

Evidence form (CMS 2728), used to register patients at

the onset of ESRD, the Death Notification form (CMS

2746), and the Facility Survey form (CMS 2744). The

latter reports the counts of patients being treated at

the end of the year, new ESRD patients starting

2018 USRDS ANNUAL DATA REPORT

treatment during the year, and patients who died

during the year. Both Medicare and non-Medicare

end-of-year patients are counted. CMS Dialysis

Facility Compare data define corporation name and

ownership type for each renal facility.

CROWNWeb is a web-based data collection system

that was implemented nationally in May 2012. It

captures clinical and administrative data from

Medicare-certified dialysis facilities for all ESRD

patients. Clinical measures are also available in the

VHA data and to a lesser degree in NHANES.

CDC National Surveillance Data was collected

during 1993-1997 and 1999-2002. It was a non-patient

specific survey of dialysis facilities on patient and staff

counts, membrane types, reuse practices, water

treatment methods, therapy types, vascular access use,

antibiotic use, hepatitis vaccination, and conversion

rates (for both staff and patients), as well as the

incidence of HIV, AIDS, and tuberculosis.

Population data are from the 2000 and 2010 United

States Census, and incorporate CDC postcensal and

intercensal population estimates. USRDS summarizes

the data with different race and ethnicity categories at

state and national levels.

Summary/Key Findings

Readers are referred to the 2018 USRDS ADR

Infographic on the USRDS website for an overview of

key highlights. The following paragraphs represent

only an outline of some of the salient findings

reported in the 2018 ADR. More detailed commentary

and the USRDS Special Studies reports are presented

within the individual chapters of the ADR.

VOLUME 1: CHRONIC KIDNEY DISEASE IN

THE UNITED STATES

Volume 1 of the 2018 USRDS ADR provides an

analysis of chronic kidney disease (CKD) in the United

States. It includes the following chapters as a road

map to the early stages of kidney disease: CKD in the

General Population (Chapter 1); Identification and Care

of Patients with CKD (Chapter 2); Morbidity and

Mortality in Patients with CKD (Chapter 3);

Cardiovascular Disease in Patients with CKD (Chapter

4); Acute Kidney Injury (Chapter 5); Healthcare

Expenditures for Persons with CKD (Chapter 6);

Prescription Drug Coverage in Patients with CKD

(Chapter 7); and the USRDS Special Study Center

report on Transition of Care in Chronic Kidney Disease

(Chapter 9 ).

Through the analyses and investigations in these

chapters, we tell the story of CKD — one that is

important not only to the domestic and international

renal communities, but for the general population as

well. It is important for everyone to understand and

care about the growing implications of kidney disease.

These chapters synthesize a wealth of data and

describe how this often silent condition can be

recognized. Throughout these chapters, we present

status and trends. We discuss risk prediction and

prevention, disease management, and opportunities to

slow disease progression. We discuss the interactions

with common comorbid conditions and emphasize

the need for interventions before reaching the often-

irreversible need for renal replacement therapy.

CHAPTER 1: CKD IN THE GENERAL POPULATION

Overall, chronic kidney disease (CKD) prevalence

has remained relatively stable during the last two

decades. Prevalence of CKD (Stages 1-5) in the general

U.S. adult population was 14.8% in 2013-2016, based on

NHANES data. CKD Stage 3 (6.4%) was the most

prevalent (Figure 1.1). In the general U.S. population

during the years 2013-2016, the prevalence of a urinary

albumin-to-creatinine ratio (ACR) of >10 mg/g of

creatinine was 33%, including 8.5% with ACR 30–300

mg/g and 1.6% with ACR >300 mg/g (Figure 1.3). In

the future, we anticipate that a subset NHANES

sample will undergo repeat testing of both blood and

urine, allowing assessment of CKD prevalence using

the persistence criterion of the KDIGO definition.

In light of the 2017 blood pressure guidelines from the

American College of Cardiology/American Heart

Association (ACC/AHA), this year we examine

hypertension control at both 130/80 mm Hg and 140/90

mm Hg. In a comparison of four cohorts of NHANES

participants (2001-2004, 2005-2008, 2009-2012, and 2013-

2016), little change was seen among individuals without

CKD, but among individuals with CKD, the percentage

within the ACC/AHA guidelines has improved from

EXECUTIVE SUMMARY

40.4% to 48.8% for BP <130/80 and from 61.5% to 68.4%

for BP <140/90 (Figures 1.10.b & 1.10.a).

The prevalence of self-reported CKD remains very

low in the U.S. general population. Comparing these

same four NHANES cohorts, we continue to see little

improvement in the percentage of individuals with

CKD who were aware of their disease in the early

stages, but among individuals in Stage 4, CKD

awareness increased from 36% to 57%. Even for

individuals with hypertension (HTN) and diabetes

mellitus (DM), only 15% were aware of their kidney

disease.

CHAPTER 2: IDENTIFICATION AND CARE OF PATIENTS

WITH CKD

Over half of patients in the Medicare 5% sample

(aged 65 and older) had at least one of three

diagnosed chronic conditions – chronic kidney disease

(CKD), cardiovascular disease (CVD), or diabetes

mellitus (DM), while 19.9% had two or more of these

conditions. Within a younger population derived from

the Optum Clinformatics™ Data Mart (ages 22-64

years), 10.6% had at least one of the three conditions,

and 1.6% had two or more. As indicated by diagnosis

claims and biochemical data from the Department of

Veterans Affairs (VA), 15.6% of patients had at least

one of the three conditions, while 2.4% had at least

two (Table 2.2.b).

The proportion of patients with recognized CKD in

the Medicare 5% sample has grown steadily, from

2.7% in 2000 to 13.8% in 2016 (Figure 2.2). In the

Medicare 5% sample and VA data, 13.8% and 14.9% of

patients had a diagnosis of CKD in 2016, as opposed to

only 2.0% of patients in the Optum Clinformatics™

population (Table 2.4).

Testing for urine albumin is recommended for

patients with DM. Among Medicare patients with a

diagnosis of DM, claims data indicated that testing for

urine albumin has become more common, but was

conducted for less than half of these patients—41.8%

in 2016, up from 26.4% in 2006. In 2016, urine albumin

testing was performed in 49.9% of diabetic Medicare

patients who also had diagnoses of CKD and

hypertension (HTN). Patterns were similar in the

Optum Clinformatics™ population, but with

somewhat lower rates of testing (Figures 2.3 and 2.4).

Among Medicare patients with recognized CKD in

2015, patients who saw a nephrologist were roughly

twice as likely to have a claim for urine albumin

testing in 2016 (55.4%) than those who saw only a

primary care physician (26.7%; Figure 2.5).

CHAPTER 3: MORBIDITY AND MORTALITY IN PATIENTS

WITH CKD

This chapter considers mortality, hospitalization

and readmissions among chronic kidney disease

(CKD) patients using the Medicare 5% sample and

Optum Clinformatics™ data from a commercial

insurer.

In 2016, Medicare patients with CKD experienced a

mortality rate of 122.6 per 1,000 patient-years. When

adjusted for sex, age, and race, the rate remained more

than double the 43.1 per 1,000 patient-years of those

without CKD. Mortality rates increased with CKD

severity, but the gap has narrowed between CKD and

non-CKD patients from 2004 to 2016 (Table 3.1 and

Figure 3.1). Male patients without CKD experienced

higher adjusted mortality rates of 48.2 per 1,000

patient-years than did females, at 39.2. This relative

difference was similar among those with CKD, with an

adjusted mortality rate of 114.4 per 1,000 patient-years

for males and 94.9 for females (Table 3.1 and Figure

3.4). In 2016, Medicare age and sex adjusted mortality

rates were 104.2 per 1,000 patient-years for Whites and

106.6 per 1,000 patient-years for Blacks/African

Americans (Figure 3.5).

Adjusted hospitalization rates declined from 2015 to

2016 in both the Medicare and Optum Clinformatics™

CKD and non-CKD patients. The decline was greater for

CKD patients than for patients without CKD in both

populations (Figure 3.7). Not surprisingly, among

Medicare patients, after adjustment for sex and race,

rates of hospitalization in older patients were greater

than for younger age cohorts. In the CKD group,

hospitalization rates for those over 85 years was 39.7%

higher than among those aged 66 to 69 years: 706.2 vs.

505.4 admissions per 1,000 patient-years at risk (Figure

3.12). Black patients with CKD had higher adjusted rates

of hospitalization than did Whites and Other races

(651.8 vs. 568.3 vs. 471.1 per 1,000 patient-years).

Disparities in outcomes increased with disease severity

(Figure 3.14). At 21.6%, unadjusted rates of hospital

2018 USRDS ANNUAL DATA REPORT

xii

readmission in Medicare patients with CKD were higher

than the 15.3% for those without CKD (Table 3.3).

CHAPTER 4: CARDIOVASCULAR DISEASE IN PATIENTS

WITH CKD

The prevalence of cardiovascular disease (CVD)

was 64.5% among patients aged 66 and older who had

chronic kidney disease (CKD), compared to 32.4%

among those who did not have CKD (Table 4.1). The

presence of CKD is associated with worsened short-

and long-term prognosis for many common

cardiovascular diseases. For example, the adjusted

two-year survival of patients with acute myocardial

infarction (AMI) and without a diagnosis of CKD was

82%, compared with 75% for CKD Stage 1-2 patients

and 59% for Stage 4-5 patients (Figure 4.2). The

presence of cardiovascular disease is also associated

with worsened short- and long-term prognosis for

patients with CKD. Over a two-year period, Medicare

patients with both heart failure and CKD had an

adjusted survival probability of 77.8%, compared to

90.2% for those with CKD alone (Figure 4.5).

Atrial fibrillation (AF) was common among Medicare

patients with CKD (23.8%). The prevalence of AF was

higher among males, older persons, and patients with

hypertension (HTN), advanced stages of CKD, and

heart failure (HF). Nearly half of CKD patients with

heart failure had a diagnosis of AF (Table 4.5).

Angiotensin converting enzyme inhibitors (ACEs)

and angiotensin receptor blockers (ARBs) are

mainstays of heart failure therapy and were prescribed

to 59.9% of CKD patients with HF, compared to 61.2%

of non-CKD patients with HF. Although direct oral

anticoagulants have been less studied among patients

with CKD, these drugs were prescribed to 30.9% of

patients with AF and CKD, as compared with 33.2% of

patients with AF and no CKD (Table 4.4).

CHAPTER 5: ACUTE KIDNEY INJURY

In 2016, 4.4% of Medicare fee-for-service

beneficiaries experienced a hospitalization

complicated by acute kidney injury (AKI), double the

proportion of 2.2% in 2006 (Figure 5.1). Risk of AKI

increases with age and in the presence of

comorbidities such as chronic kidney disease (CKD)

and diabetes mellitus (DM). About 1 in 5 hospitalized

Medicare patients with both CKD and DM experience

a hospitalization with AKI each year (Figure 5.5).

Among hospitalized veterans aged 22+ years, 25.4%

met Kidney Disease: Improving Global Outcomes

(KDIGO) guidelines for AKI as defined using serum

creatinine-based criteria (Table A). This included

21.4%, 0.8%, and 3.2% of patients with Stage 1, Stage 2,

and Stage 3 AKI (Table 5.2). Just over half (52.6%) of

patients meeting criteria for AKI were given a

diagnosis of AKI. In 2014, Medicare patients aged 66+

years who were hospitalized for AKI had a 36%

cumulative probability of a recurrent AKI

hospitalization within one year (Figure 5.6.a). For

Optum Clinformatics™ patients aged 22+ years, the

probability of recurrent AKI hospitalization was 23%

(Figure 5.7.a).

Among Medicare patients without a pre-existing

diagnosis of CKD, 30.8% were given a new diagnosis of

CKD in the year following an AKI hospitalization

(Figure 5.10.a). In the Optum Clinformatics™

population, 33.8% of patients with an AKI

hospitalization were newly classified as having CKD in

the subsequent year (Figure 5.10.b). In contrast,

among Medicare patients with a “new” diagnosis of

CKD in 2016, 25% had an AKI hospitalization in the

preceding year.

CHAPTER 6: CKD AMONG CHILDREN AND ADOLESCENTS

For the first time, the 2018 ADR includes a chapter

on chronic kidney disease (CKD) among children in

the United States, using data from a single commercial

payer. Among those with healthcare coverage, a

diagnosis of CKD was made among 2.7 per 1,000

children (Table 6.2). Hospitalization rates were 12

times higher for children with CKD than for all

children (Table 6.3). Between 2006 and 2016,

healthcare expenditures increased by 50% for children

with CKD, compared to 25% for children without CKD

(Figure 6.3). Healthcare expenditures for children with

CKD in 2016 were 7.6 times higher than expenditures

for children without CKD (Figure 6.3).

CHAPTER 7: HEALTHCARE EXPENDITURES FOR PERSONS

WITH CKD

In the 2018 Annual Data Report (ADR), we

introduce information from the Optum

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Clinformatics™ DataMart for persons with Medicare

Advantage and commercial managed care coverage to

provide a more comprehensive examination of the

financial costs necessary to provide care to

beneficiaries with chronic kidney disease (CKD).

Medicare spending for all beneficiaries who had CKD

(12.5% of total) exceeded $79 billion in 2016, an

increase of 23% from 2015 (Tables 7.1 and 7.3). When

adding an additional $35 billion for end-stage renal

disease (ESRD) costs (Figure 9.2), total Medicare

spending on both CKD and ESRD was over $114 billion,

representing 23% of total Medicare fee-for-service

(FFS) spending. In 2016, Medicare spending for

beneficiaries with CKD aged 65 and older exceeded

$67 billion, representing 25% of all Medicare spending

in this age group (Figure 7.1). Medicare expenditures

for CKD were 20% higher in 2016 than in 2015 ($55

billion).This was mostly due to an 18% increase in the

ascertainment of CKD. Medicare spending for

beneficiaries with CKD who were younger than age 65

(8% of total) exceeded $12 billion in 2016, representing

18% of total spending in this age group (Table 7.3).

Growth in total CKD spending has primarily been

driven by an increase in the number of identified

cases, particularly those in the earlier stages (CKD

Stages 1-3). Over half of 2016 Medicare spending for

beneficiaries aged 65 and older was for those who had

diagnoses of CKD, diabetes mellitus (DM), or heart

failure (HF; Figure 7.1). Spending per patient-year for

those with all three chronic conditions of CKD, DM,

and HF was more than twice as high ($39,506) as for

beneficiaries with only CKD ($16,176; Table 7.1). The

analysis of expenses for beneficiaries with CKD

indicates the effect of cost-containment efforts in this

population, and avenues for potential savings.

Reduction in expenditures could be achieved through

the prevention of disease progression to later stages of

CKD, and prevention of the development of

concurrent chronic conditions such as DM and HF.

CHAPTER 8: MEDICARE PART D PRESCRIPTION DRUG

COVERAGE IN PATIENTS WITH CKD

Approximately 73.7% of chronic kidney disease

(CKD) patients enrolled in Medicare Part D in 2016,

including both the fee-for-service stand-alone and

Medicare Advantage plans. The Part D enrollment rate

for the CKD group was slightly higher than in the

general Medicare population (69.5%; Figure 8.1). The

percentage of Medicare beneficiaries who received the

Low-income Subsidy (LIS) was higher for CKD

patients across all age and race categories than in the

general Medicare population (Figures 8.2 and 8.3). As

compared to White beneficiaries (29.3%), much

higher proportions of Asian (73.8%) and Black/

African American (62.8%) CKD Part D beneficiaries

qualified for the LIS (Figure 8.3).

Among patients with stand-alone Part D plans, per

person per year (PPPY) insurance spending on

prescriptions was 1.6 times higher for Medicare

patients with CKD than for general beneficiaries

($4,941 vs. $3,027) in 2016. Spending for CKD patients

with Medicare Advantage plans was 1.6 times higher

($2,926, vs. $1,834), and 4.1 times higher for those with

managed care coverage ($4,164 vs. $1,013; Figure 8.5.a).

Total spending for Part D-covered medications in 2016

was more than twice as high for patients with the LIS

than for those without, regardless of the presence of

CKD. Patient out-of-pocket costs for LIS patients

represented only a 1.2%-1.3% share of these total

expenditures, as compared to 25.3%-27.0% in each of

the non-LIS populations (Figure 8.5.b). Prescriptions

for lipid-lowering agents, antibacterials, renin-

angiotensin-aldosterone system inhibitors, and β-

adrenergic blocking agents (beta blockers) were each

filled by more than 50% of Medicare CKD patients

during 2016 (Table 8.6). CKD patients with Medicare

Advantage and managed care coverage showed similar

patterns of use for these drug classes. By drug class,

the highest medication expenditures for patients with

CKD were for antidiabetic agents, followed by

antineoplastic agents, antivirals, and lipid-lowering

agents (Table 8.7). The overall proportions of CKD

patients using prescription non-steroidal anti-

inflammatory agents (NSAIDs) and opioids were

16.4% and 43.8%, respectively (Figures 8.6-8.7).

VOLUME 2: END-STAGE RENAL DISEASE IN

THE UNITED STATES

Volume 2 of the ADR provides key statistics on

end-stage renal disease (ESRD) in the United States

and includes the following chapters: Incidence,

Prevalence, Patient Characteristics, and Treatment

Modalities (Chapter 1); Clinical Indicators and

2018 USRDS ANNUAL DATA REPORT

xiv

Preventive Care (Chapter 2); Vascular Access

(Chapter 3); Hospitalizations, Readmissions,

Emergency Department Visits, and Observation Stays

(Chapter 4); Mortality (Chapter 5); Transplantation

(Chapter 6); ESRD among Children, Adolescents, and

Young Adults (Chapter 7); Cardiovascular Disease in

Patients with ESRD (Chapter 8); Healthcare

Expenditures for Persons with ESRD (Chapter 9);

Prescription Drug Coverage in Patients with ESRD

(Chapter 10); International Comparisons (Chapter 11);

and the USRDS Special Study Center report on End-of-

Life Care for Patients with ESRD (Chapter 12). In

addition, we also present a chapter on the Healthy

People 2020 program, which assesses progress on the

HP2020 kidney disease objectives.

CHAPTER 1: INCIDENCE, PREVALENCE, PATIENT

CHARACTERISTICS, AND TREATMENT MODALITIES

The age-sex-race standardized incidence rate of

end-stage renal disease (ESRD) in the United States

rose sharply in the 1980s and 1990s, leveled off in early

2006, and has declined slightly since its peak in 2006

(Figure 1.1). In 2016, there were 124,675 newly reported

cases of ESRD; the unadjusted (crude) incidence rate

was 373.4 per million/year (Table 1.1). Since 2011, the

crude rate had risen; however, the standardized rate

appears to have plateaued (Figure 1.1). In 2016, the age-

sex-standardized ESRD incidence rate ratio, compared

with Whites, was 2.9 for Blacks/African Americans, 1.2

for American Indians/Alaska Natives, and 1.1 for

Asians (Figure 1.5). All these represent reductions in

the relative rate of ESRD for these populations

compared to Whites over the past 16 years. The

incidence rate ratio for Hispanics versus non-

Hispanics was 1.3 (Figure 1.6). Based on 2013 data, the

lifetime risk of being diagnosed with ESRD from birth

was 4.0% in males and 2.9% in females. Among males,

the lifetime risk ranged from a low of 3.4% in Whites

to a high of 8.1% in Blacks/African Americans, while in

females, it ranged from 2.3% in Whites to 6.8% in

Blacks/African Americans. (Figure 1.7 and Table 1.3).

On December 31, 2016, there were 726,331 prevalent

cases of ESRD; the crude prevalence was 2,160.7 per

million in the U.S. population (Table 1.4). The number

of prevalent ESRD cases has continued to rise by

about 20,000 cases per year (Table 1.4). In contrast to

the standardized incidence rate, the age-sex-race-

standardized prevalence of ESRD has continued to

increase since 2006 (Tables 1.1 and 1.4).

In 2016, 35.4% of incident ESRD patients received

little or no pre-ESRD nephrology care (Table 1.8.a).

Mean eGFR at initiation of dialysis in 2016 was 9.7

ml/min/1.73 m

(Table 1.10), down from a peak of 10.4

in 2010. The percentage of incident ESRD cases

starting with eGFR ≥10 ml/min/1.73 m

rose from

12.9% in 1996 to 42.6% in 2010, but decreased to 38.6%

in 2016 (Figure 1.19).

CHAPTER 2: CLINICAL INDICATORS AND PREVENTIVE

CARE

In May 2017, the majority (64.5%) of hemodialysis

(HD) patients had hemoglobin (Hgb) levels from 10 to

<12 g/dL, while 14.5% had Hgb ≥12 g/dL, 14.4% had

Hgb from 9 to <10 g/dL, and 6.6% had Hgb <9 g/dL.

The mean Hgb was 10.8 g/dL (Figure 2.1.b). The

majority (56.1%) of peritoneal dialysis (PD) patients

had Hgb levels from 10 to <12 g/dL, while 21.4% had

Hgb ≥12 g/dL, 15.2% had Hgb from 9 to <10 g/dL, and

7.3% had Hgb <9 g/dL. The mean Hgb was 10.9 g/dL

(Figure 2.1.b). As of 2016, three different

erythropoiesis-stimulating agents (ESAs) were

prescribed to dialysis patients in the United States.

December 2016 claims data indicated monthly use

rates among HD patients on dialysis ≥90 days of 34.4%

for epoetin (EPO) alfa, 17.9% for darbepoetin, and

24.4% for pegylated EPO (PEG-EPO) beta. Twenty-

two percent of HD patients were not using an ESA.

Among PD patients, 31.2% were using EPO alfa, 13.0%

darbepoetin, and 13.1% PEG-EPO, while 41.7% of PD

patients were not using an ESA (Figures 2.2.d and

2.8.d.). For U.S. HD patients between 2015 and 2016, a

small increase was seen in monthly percent

intravenous (IV) iron use (60.0% to 61.8%), whereas,

mean monthly IV iron dose declined slightly (from

294.1 mg to 291.8 mg; Figure 2.4). Similarly, for PD

patients a small increase was also seen in monthly

percent IV iron use (25.3% to 26.5%) and decline in

mean monthly IV iron dose (from 196.2 mg to 190.9

mg; Figure 2.10). Serum ferritin levels increased

slightly in all dialysis patients from 2015 to 2017. As of

May 2017, 30.4% and 25.5% of HD patients had serum

ferritin levels of 801-1200 and >1200 ng/mL. Among PD

patients, 22.4% and 17.2% had serum ferritin levels of

801-1200 and >1200 ng/mL (Figures 2.6 and 2.12).

EXECUTIVE SUMMARY

In May 2017, 60.5% of HD and 57.5% of PD patients

had serum calcium levels within the range of 8.4-9.5

mg/dL. About 1.3% of HD patients and 1.9% of PD

patients had serum calcium levels greater than 10.2

mg/dL, and 16.9% of HD patients and 23.1% of PD

patients had serum calcium levels less than 8.4 mg/dL

(Figures 2.14 and 2.15). Serum phosphorus levels were

greater than 4.5 mg/dL among 66.1% of HD patients

and 71.6% of PD patients (Figures 2.16 and 2.17).

In the 2015-2016 flu season, 71.3% of patients

received an influenza vaccination. Although this rate

has been stable over the last two years, the percent

vaccinated has increased from 59.3% a decade earlier

(Figure 2.19.a).

CHAPTER 3: VASCULAR ACCESS

In 2016, 80% of patients were using a catheter at

hemodialysis (HD) initiation (Figure 3.1). At 90 days

after the initiation of HD, 69% of patients were still

using catheters (Figure 3.7.a). The percentage of

patients using an arteriovenous (AV) fistula or with a

maturing AV fistula at HD initiation increased from

28.9% to 33% over the same period (Figure 3.1). AV

fistula use at HD initiation rose from 12% to 17% over

the period 2005-2016 (Figure 3.1). AV fistula use

increased to 64% by the end of one year on HD, and to

71% by the end of two years (Figure 3.7.a). The

proportion of patients with an AV graft for vascular

access was 3% at HD initiation, 15% at one year after

initiation, and 17% at two years (Figure 3.7.a). At one

year after HD initiation, 79% of patients were using

either an AV fistula or AV graft without the presence

of a catheter. By two years, this number rose to 88%

(Figure 3.7.a). Of AV fistulas placed between June 2014

and May 2016, 39% failed to mature sufficiently for use

in dialysis. Of those that did mature, the median time

to first use was 108 days (Table 3.7). Patient

demographic characteristics appear to contribute to

success with AV fistula; at younger ages, the percent

of AV fistulas that successfully mature is higher and

the median time to first use is somewhat shorter

(Table 3.7). Males had a higher AV fistula maturation

rate compared to females, as well as shorter time to

first use. Blacks were observed to have the highest AV

fistula maturation failure rates.

CHAPTER 4: HOSPITALIZATIONS, READMISSIONS,

EMERGENCY DEPARTMENT VISITS, AND OBSERVATION

STAYS

End-stage renal disease (ESRD) patients continue

to experience a relatively high frequency of

hospitalization, although over the last decade the

frequency of admissions has declined. Between 2007

and 2016, the adjusted hospital admission rate for

dialysis patients declined from 2.0 to 1.7 per patient-

year (PPY), a reduction of 15%. During that same

period, the admission rate for transplant patients

declined from 1.0 to 0.8 PPY, a 20% reduction (Figure

4.1). Hospitalization rates for hemodialysis (HD)

patients were highest in their first year but fell

considerably through the first three years of HD,

whereas peritoneal dialysis (PD) patients generally

experienced increasing hospitalization rates many

years after dialysis initiation (Figure 4.3). All-cause

hospitalization rates among adult HD patients

decreased by 14.2% from 2007 to 2014 and remained

stable in 2015-2016 (see Table 4.1). Hospitalizations

due to cardiovascular events and those for vascular

access infection fell by 18.9% and 54.6% from 2007 to

2016, respectively. Select patient groups continue to

exhibit more frequent hospitalization. For 2015-2016,

adjusted HD patient hospitalization rates were higher

for those aged 22–44 years or 75 years and older,

females, and those of non-Hispanic White or

Black/African American race, and for those who had

diabetes as their primary cause of kidney failure

(Table 4.1).

The frequency of dialysis patient visits to the

emergency department (ED) has increased over time.

Between 2007 and 2016, unadjusted ED visit rates for

HD patients increased from 2.6 to 3.0 PPY, while rates

for peritoneal dialysis (PD) patients increased from 2.2

to 2.4 PPY, and rates for transplant patients increased

from 1.3 to 1.4 PPY (Figure 4.14). Observation stays were

relatively rare for ESRD patients, but approximately

doubled in frequency from 2007-2016. Unadjusted rates

of observation stays for HD patients increased from 0.16

to 0.38 PPY, while rates for PD patients increased from

0.12 to 0.25 PPY, and rates for transplant patients

increased from 0.08 to 0.15 PPY (Figure 4.17).

Among ESRD patients in 2016, more than one in three

live hospital discharges were followed by a readmission

2018 USRDS ANNUAL DATA REPORT

xvi

within 30 days (35.4%), compared to 21.6% for patients

with chronic kidney disease (CKD) and only 15.3% for

older Medicare beneficiaries without a diagnosis of kidney

disease (Figure 4.7). The frequency of 30-day readmissions

among dialysis patients was stable from 2007-2011 at

approximately 39%, fell somewhat in 2012-2013, and has

remained at approximately 37% during 2014-2016.

Readmissions for transplant patients were approximately

8 percentage points lower but followed a similar time

trend (Figure 4.8).

CHAPTER 5: MORTALITY

The decline in mortality in the end-stage renal

disease (ESRD) population has important implications

for both patients and resource allocation. Increasing

lifespan among ESRD patients is a primary reason for

continued growth in the prevalent ESRD population.

The relative decline in mortality for dialysis patients in

the past 20 years has been similar to that of Medicare

patients with cancer and diabetes, and greater than for

Medicare patients with cerebrovascular disease or an

acute myocardial infarction (Table 5.5, Figure 5.5). In

2016, adjusted mortality rates for ESRD, dialysis, and

transplant patients were 134, 164, and 29 per 1,000

patient-years. By dialysis modality, mortality rates

were 166 for hemodialysis (HD) patients and 154 for

peritoneal dialysis (PD) patients, per 1,000 patient-

years (Figure 5.1). Between 2001 and 2016, adjusted

mortality rates decreased for dialysis patients by 29%.

The net reductions in mortality from 2001 to 2016 were

28% for HD patients and 43% for PD patients (Figure

5.1). Between 2001 and 2016, unadjusted (crude)

mortality rates decreased by 2% for transplant

recipients. After accounting for changes in population

characteristics (primarily increasing age), trends in

post-transplant mortality were much more

pronounced, with adjusted mortality rates decreasing

by 40% (Figure 5.1). Patterns of mortality during the

first year of dialysis differed substantially by modality.

For HD patients, reported mortality was highest in

month two, but declined thereafter; this effect was

more pronounced for patients aged 65 and older. In

contrast, mortality for PD patients was relatively low

initially, but rose slightly over the course of the year

(Figure 5.3). Dialysis patients over the age of 65

continued to have substantially higher mortality

compared to the general population and Medicare

populations with cancer, diabetes, or cardiovascular

disease.

CHAPTER 6: TRANSPLANTATION

In 2016, 20,161 kidney transplants were performed

in the United States (19,301 were kidney-alone; Figure

6.6). Fewer than a third (28%) of kidneys transplanted

in 2016 were from living donors (Figure 6.6). From

2015 to 2016, the cumulative number of recipients with

a functioning kidney transplant increased by 3.4%,

from 208,032 to a total of 215,061 (Figure 6.7). On

December 31, 2016, the kidney transplant waiting list

had 81,418 candidates on dialysis, 51,238 (62.9%) of

whom were active. Eighty-five percent of all

candidates were awaiting their first transplant (Figure

6.1). Among candidates newly wait-listed for either a

first or repeat kidney-alone transplant (living or

deceased-donor) during 2011, the median waiting time

to transplant was 4.0 years (Figure 6.4). This waiting

time varied greatly by region of the country, from a

low of 1.4 years in Nebraska to a high of 5.1 years in

Georgia (Reference Table E.2.2). The number of

deceased kidney donors, aged 1-74 years, with at least

one kidney retrieved increased by 62.7%, from 5,981 in

2001 to 9,732 in 2016 (Figure 6.19.a).

The rate of kidney donation from deceased

Blacks/African Americans nearly doubled from 2002

to 2016, from 4.5 to 7.9 donations per 1,000 deaths

(Figure 6.21.b). This rate overtook that of Whites in

2009. Asians consistently had the highest rate of

deceased kidney donation during this time, at about 9

per 1,000 deaths. The number of kidney paired

donation transplants has risen sharply since 2005,

with 642 performed in 2016, which represented 11% of

living-donor transplants that year. The rate plateaued

during 2012-2014 but increased again in 2016 (Figure

6.18). Since 1999, the probabilities of graft survival

have improved among recipients of both living and

deceased-donor kidney transplants, over both the

short-term (one-year survival) and long-term (five and

ten-year survival) (Figure 6.25). In 2015, the

probabilities of one-year graft survival were 93% for

deceased and 98% for living-donor kidney transplant

recipients (Figure 6.25). In 2015, the probabilities of

patient survival within one-year post-transplant were

96% and 99% of deceased- and living-donor kidney

EXECUTIVE SUMMARY

xvii

transplant recipients (Figure 2.6). The one-year graft-

survival and patient-survival advantages experienced

by living-donor transplant recipients persisted at five

and ten years post-transplant (Figures 6.25 and 6.26).

CHAPTER 7: ESRD AMONG CHILDREN, ADOLESCENTS,

AND YOUNG ADULTS

The number of children and adolescents beginning

end-stage renal disease (ESRD) care is steadily

decreasing from a high of 17.5 per million in 2004 to

13.8 per million population in 2016, representing a

decrease of 21.1% (Figure 7.1.a). As of December 31,

2016, the point prevalence of children and adolescents,

0 to 21 years of age, with ESRD was 9,721, or 99.1 per

million population (Figure 7.1.b). The one-year ESRD

patient mortality decreased by 20.4% over the last

decade, with the greatest improvement observed in

the 0-4 year age group with a 35.0% decrease. (Figures

7.8.a and 7.8.b). Twenty percent of incident and 72%

of prevalent children and adolescents with ESRD have

kidney transplants, in 2016 (Figures 7.1.a and 7.1.b).

Since 1978, a total of 19,441 survivors of childhood

onset ESRD have transitioned into adulthood and 81%

of these individuals were still alive as of December 31,

2016 (Figure 7.17).

CHAPTER 8: CARDIOVASCULAR DISEASE (CVD) IN

PATIENTS WITH ESRD

Cardiovascular disease (CVD) is common in adult

end-stage renal disease (ESRD) patients, with

coronary artery disease (CAD) and heart failure (HF)

being the most common conditions (Table 8.1). Even

relatively young ESRD patients—those aged 22-44 and

45-64 years—are likely to suffer from cardiovascular

disease (Figures 8.2.a and 8.2.b). The presence of

cardiovascular disease is associated with both worse

short- and long-term survival in adult ESRD patients

(Figure 8.3). Only about two-thirds of dialysis or

transplant patients with acute myocardial infarction

(AMI) received beta-blocker medications. Similarly,

among ESRD patients with HF, fewer than half

received angiotensin converting enzyme inhibitors

(ACEIs) and angiotensin receptor blockers (ARBs).

Although many ESRD patients with atrial fibrillation

(AF) are at elevated risk of stroke, only about one-

third of dialysis patients with AF were treated with

warfarin (Table 8.3).

CHAPTER 9: HEALTHCARE EXPENDITURES FOR PERSONS

WITH ESRD

Between 2015 and 2016, Medicare fee-for-service

spending for beneficiaries with end-stage renal disease

(ESRD) rose by 4.6%, from $33.8 billion to $35.4

billion, accounting for 7.2% of overall Medicare paid

claims, a figure that has remained stable since 2004

(Figure 9.2). This marks the fifth year of modest

growth relative to historical trends, and follows the

2011 implementation of the bundled payment system.

When $79 billion in expenditures for chronic kidney

disease (CKD) are added, total Medicare expenditures

for both CKD and ESRD are over $114 billion, an

increase of 16%. In 2016, ESRD spending per person

per year (PPPY) increased by 2.5% (Figure 9.4). For

the second year in a row, most of the increase in

Medicare expenditures for beneficiaries with ESRD

was attributable to higher PPPY spending, rather than

growth in the number of covered lives. For

hemodialysis (HD) care, both total and PPPY spending

increased between 2015 ($26.8 billion and $88,782) and

2016 ($28.0 billion and $90,971) (Figures 9.7 and 9.8).

During this period, total peritoneal dialysis (PD)

spending grew by 5.7%, as the share of patients

receiving PD continued to rise. However, while PPPY

spending on PD rose 1.4% from 2015 to 2016, PD

remained less costly on a per-patient basis than HD

(Figures 9.7 and 9.8). Total and PPPY kidney

transplant spending have increased by 4.6% and 2.1%.

Total spending for transplant patients increased from

$3.3 billion to $3.4 billion, and per capita spending

increased from $34,080 to $34,780 (Figures 9.7 and

9.8). Total inpatient spending for patients with ESRD

grew rapidly from 2004 until 2009, followed by slower

growth from 2009 until 2011, remained quite stable

from 2011 to 2015, but then increased by 5.3% in 2016

(Figure 9.5).

CHAPTER 10: PRESCRIPTION DRUG COVERAGE IN

PATIENTS WITH ESRD

In 2018, this chapter continues to report on

analgesic use and updates the map of non-steroidal

anti-inflammatory agents (NSAIDs) and opioid use in

the United States using 2016 data. Further, because of

increasing use of high-cost antivirals nationally, this

year we investigate the spending and utilization rates

2018 USRDS ANNUAL DATA REPORT

xviii

of antivirals, including prescription antiretrovirals,

nucleosides and nucleotides, and protease inhibitors.

Among beneficiaries with Medicare Part D

enrollment, a higher proportion of those treated with

hemodialysis (HD; 65.5%), peritoneal dialysis (PD;

52.3%), and kidney transplant (50.3%) received the

Low-income Subsidy (LIS) than did the general

Medicare population (30.2%; Figure 10.1). In 2016, per

patient per year (PPPY) Medicare Part D spending on

prescriptions for end-stage renal disease (ESRD)

patients with stand-alone Part D plans was 4.1 times

higher than among the general Medicare population

($13,310 vs. $3,559; Figure 10.5.a). Of patients enrolled

in stand-alone Part D plans, dialysis patients had a

higher PPPY spending on prescriptions than did

transplant patients (HD, $14,922; PD, $13,882;

transplant, $8,693; Figure 10.5.a). In both the general

Medicare and ESRD populations, PPPY Part D

spending was 2.8-3.6 times greater for beneficiaries

with LIS benefits than for those without. This

difference reflects both higher utilization among those

with LIS benefits and the higher share of spending

covered by Medicare for LIS beneficiaries. LIS

beneficiaries’ out-of-pocket costs represented only

0.6%-1.2% of total Part D expenditures, compared to

21.6-26.9% in the non-LIS populations (Figure 10.5.b).

In 2016, ESRD patients were most frequently

prescribed ion-removing agents, β-adrenergic

blocking agents (beta blockers), antibacterials,

analgesics, antipyretics, and lipid-lowering agents

(Table 10.6). The highest costing medications for

ESRD patients were ion-removing agents, cinacalcet,

antidiabetic agents, antivirals, and

immunosuppressive agents (Table 10.7). In the United

States, the overall proportions of ESRD patients using

prescription NSAIDs and opioids were 8.3% and

49.0%, respectively (Figures 10.6 and 10.7). In 2016,

approximately 5.8%, 5.6%, and 24.1% of HD, PD, and

transplant patients had at least one filled prescription

antiviral; PPPY Medicare Part D spending among

these users was $918, $844, and $2,104, respectively

(Figures 10.9 and 10.10).

CHAPTER 11: INTERNATIONAL COMPARISONS

This chapter now includes data received from 74

countries. In 2016, as seen over the past decade,

Taiwan, the United States, and the Jalisco region of

Mexico reported the highest incidence of treated end-

stage renal disease (ESRD), with rates of 493, 378, and

355 patients per million general population (PMP;

Figure 11.2), respectively. Nearly 40% of countries had

incidence rates of treated ESRD <120 patients PMP,

with South Africa reporting the lowest incidence rate

of 22 treated ESRD patients PMP in 2016. In 2016, large

variation was seen across countries in whether

diabetes mellitus (DM) was the primary cause of ESRD

among incident treated ESRD patients, ranging from

approximately 66% of incident treated ESRD patients

in Malaysia, Singapore, and the Jalisco region of

Mexico, to less than 16% in Norway, Latvia, and

Romania (Figure 11.4.b). From 2003 to 2016, the Jalisco

region of Mexico and Malaysia had the highest average

yearly increases overall in the rates of ESRD incidence

due to diabetes (Figure 11.5). In 2016, among young

adults (aged 20-44 years), the United States reported

the highest ESRD incidence rate at 134 PMP, followed

by Malaysia at 111 PMP, with most countries having

treated ESRD incidence rates <50 PMP in this young

age group (Figure 11.7a). Large international variation

exists in the use of the different renal replacement

therapies (RRT; Figure 11.12). In approximately one-

fourth of countries, 50%-70% of treated ESRD patients

are living with a kidney transplant—particularly in

northern European countries. In contrast, in

approximately one-third of countries, less than 20% of

treated ESRD patients are living with a kidney

transplant. In most nations, in-center hemodialysis

(HD) was the predominant RRT modality.

VOLUME 3, CHAPTER 1: HEALTHY PEOPLE

2020

In this chapter, we examine data for 10 Healthy

People 2020 (HP2020) objectives spanning 19 total

indicators for which the USRDS serves as the official

data source. As in previous Annual Data Reports

(ADR), we present data overall, and stratified by race,

sex, and age groups to highlight any disparities in

progress. In 2016, 11 of the 18 HP2020 indicators with

specific targets met the established goals. Key areas

where substantial improvement has been observed

include mortality among dialysis patients and vascular

access. Conversely, the incidence rates of end-stage

renal disease (ESRD) overall, and ESRD due to

EXECUTIVE SUMMARY

xix

diabetes, remain above HP2020 targets. State-level

comparison maps showed marked geographic

variation for HP2020 Objectives CKD-10 (Proportion

of ESRD patients receiving care from a nephrologist at

least 12 months before the start of renal replacement

therapy; Figure 1) and CKD-13.1 (Proportion of patients

receiving a kidney transplant within three years of

end-stage renal disease; Figure 2). Forty-eight states

achieved the HP2020 target for CKD-10, while nine

achieved the target for CKD-13.1. For HP2020

objectives relating to vascular access, we present data

from CROWNWeb examining HP2020 Objectives

CKD 11-1 (Proportion of adult hemodialysis patients

who use arteriovenous fistulas as the primary mode of

vascular access; Table 9) and CKD 11-2 (Proportion of

adult hemodialysis patients who use catheters as the

only mode of vascular access; Table 10). In 2016, the

overall proportion of prevalent patients using an

arteriovenous fistula was 64.1%, and this appears to

have plateaued since 2012. The all-cause mortality

among prevalent dialysis patients in 2016 was 173.1

deaths per 1,000 patient-years (HP2020 objective

CKD-14.1, Table 15). This rate represents a 16.8%

decrease in the mortality rate since 2007. While this

rate is lower than in 2015 (174.0 deaths per 1,000

patient-years), it is still higher than in 2014, when the

rate was lower than it has ever been at 171.6 deaths per

1,000 patient-years.

2018 USRDS ANNUAL DATA REPORT

Notes