Recent progress in the prevention and treatment of end-stage renal disease (ESRD) in the United States give reason for "cautious optimism," but skyrocketing costs are a major concern, according to a Special Article in the October Journal of the American Society of Nephrology.
Drs. Robert Foley and Allan J. Collins of the United States Renal Data System (USRDS) and University of Minnesota summarize key findings from the 2006 USRDS Annual Data Report. The USRDS update assembles the most recent nationwide data on the incidence, treatment, and outcomes of ESRD, permanent loss of kidney function requiring "renal replacement therapy" (dialysis or kidney transplantation).
"The new update describes successes, failures, and challenges for the future," comments Dr. Foley. "For example, improvements in survival expectations and increased use of fistulas for hemodialysis represent progress. In contrast, ever-increasing numbers of new patients with ESRD tend to suggest that preventive care and health policy practices have been less than optimal."
In 2004, the most recent year for which complete data were available, 104,364 Americans (approximately 0.03 percent of the population) started dialysis or received a kidney transplant. This represented nearly a one percent decline in renal replacement therapy, compared with the previous year.
The decline is especially encouraging at a time when type 2 diabetes mellitus, one of the major risk factors for kidney disease, has reached epidemic proportions. The data suggest that improvements in preventive care may be helping to reduce diabetes-related kidney disease, although several years of new data will be needed to confirm this trend.
Still, diabetes remains the leading cause of ESRD. In particular, rising rates of diabetic ESRD among younger African-American adults suggest "a looming public health crisis," according to the new report. An apparent increase in kidney disease caused by atherosclerosis (narrowing or "hardening" of the arteries) among older adults is another area of concern.
The USRDS data show improvement in several indicators of the quality of dialysis care, including evidence that patients are starting renal replacement therapy at a less-severe stage of kidney disease. The increased use of fistulas for dialysis access reduces problems associated with the use of grafts or catheters. At the same time, there is continued concern about overaggressive use of drugs called erythrocyte-stimulating agents (ESAs) for the treatment of dialysis-related anemia.
Most important, the probabilities of survival for U.S. ESRD patients have improved steadily since the late 1980s,especially remarkable since today's dialysis patients are older and sicker than the dialysis population of 20 years ago. There is some concern that the risk of death during the first year of dialysis has not shown any meaningful improvement since 1993. In contrast, the data show continued reductions in risk of death during the second through fifth years of dialysis.
"While most of these findings are grounds for cautious optimism, the same cannot be said for issues of cost," Drs. Foley and Collins write. With the continued growth of the ESRD population, costs grew by 57 percent between 1999 and 2004. "The cost implications are staggering," Dr. Foley adds. "The most recent estimates showed that Medicare costs for ESRD reached $20.1 billion, while non-Medicare costs rose to $12.4 billion." Costs for the care of ESRD patients now account for 6.7 percent of total Medicare expenditures.
In recent years, the research focus has been on chronic kidney disease (CKD),loss of kidney function that, in many patients, progresses to ESRD. "The interface between CKD and ESRD, which is very poorly understood, remains an unmet public health challenge," the authors write. Dr. Foley concludes, "If one accepts that healthcare resources are finite, prevention of ESRD has the potential to enhance the lives of people with CKD and without CKD."