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(2010) USRDS 2010 - United States Renal Data System

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Tables of contents listing all chapters<br />

in the ckd & esrd volumes, the main<br />

topics covered within them, & the<br />

reference sections & appendices;<br />

pages 7–9 of Volume One & pages<br />

195–197 of Volume Two.<br />

Chapter tables of contents<br />

listings of all two-page<br />

spreads; found on the<br />

third page of each<br />

chapter.<br />

Information map<br />

listings of central<br />

topics in the adr;<br />

pages 10–11 of Volume<br />

One & pages 200–201<br />

of Volume Two.<br />

CD-ROM both volumes<br />

of the adr, slides of<br />

������������������������<br />

of all data, &����������<br />

��������������������������<br />

with the adr.<br />

Reference tables<br />

ckd: pages 145–162 of<br />

Volume One; esrd:<br />

pages 397–460 of<br />

Volume Two.<br />

��ndin�����������n����<br />

in������nn���������������<br />

Glossary with a list of acronyms;<br />

page 180 of Volume One &<br />

page 500 of Volume<br />

Two.<br />

Chapter summaries<br />

central points from<br />

each two-page<br />

spread; found on<br />

the last page of each<br />

chapter.<br />

Index to the ckd<br />

& esrd volumes;<br />

page 185 of Volume<br />

One & page 521 of<br />

Volume Two.


united states renal data system<br />

<strong>2010</strong><br />

usrds<br />

data<br />

annual<br />

report<br />

volume<br />

���<br />

atlas of chronic kidney<br />

disease in the united states<br />

n����n����n������������������<br />

n����n����n�������������������������������������n�����������<br />

�������n�������n������������������m�����������������


<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

���<br />

ckd<br />

page 4<br />

Production of this Annual <strong>Data</strong> Report (adr) was solely funded through nih contract hhsn 267 2007 15002c / no1-dk-7-5002 with the Minneapolis<br />

Medical Research Foundation (mmrf). Most contributors to this report are employed by mmrf, with many of the physician investigators<br />

being employed by mmrf’s parent organization, Hennepin Faculty Associates. mmrf�����������������������������������coi) policies<br />

and practices governing the conduct of research within the usrds and of other research not related to the usrds. In addition to internal<br />

controls, usrds work is overseen by niddk�����������������������usrds Steering Committee, and the usrds External Advisory Committee.<br />

Listed here are those who contributed to the 2009 adr. Unless otherwise noted in parentheses, the contributor’s employer was mmrf or<br />

its parent organization, Hennepin Faculty Associates.<br />

���������������������������� Allan Collins, md, facp, usrds Director (entire adr). Robert Foley, mb, msc, usrds Deputy<br />

Director (entire adr). Blanche Chavers, md (University of Minnesota School of Medicine; Vol 2, Ch 8). David Gilbertson, phd (entire<br />

adr). Charles Herzog, md (Vol 1, Ch 5; Vol 2, Ch 9). Areef Ishani, md, ms (Vol 1, Ch 8). Kirsten Johansen, md (University of California<br />

at San Francisco; Vol 2, Ch 9). Bertram Kasiske, md (Vol 2, Ch 7). Nancy Kutner, phd (Emory University; Vol 2, Ch 9). Suying<br />

Li, phd (Vol 1, Ch 4; Vol 2, Précis & Chs 1, 6, 8; H & I tables). Jiannong Liu, phd (maps; Vol 2, Ch 10; E tables). Lih-Wen Mau, phd<br />

(Vol 1, Ch 9; Vol 2, Ch 12). Anne Murray, md, msc (Vol 1, Ch 6). Wendy St. Peter, PharmD, bcps (Vol 1, Chs 3 & 7; Vol 2, hp<strong>2010</strong><br />

& Chs 1, 5, & 11). Jon Snyder, phd (Vol 2, Ch 7). ������� administrative staff Beth Forrest, bba (Vol 2, Ch 12). ADR production<br />

Edward Constantini, ma (entire adr). Susan Everson, phd (entire adr). biostatisticians Haifeng Guo, ms (Vol 1, Ch 3;<br />

Vol 2, hp<strong>2010</strong> & Chs 5, 8, 10). Sally Gustafson, ms (Vol 2, Ch 7; e & f tables). Shuling Li, ms (Vol 1 , Ch 6; Vol 2, hp<strong>2010</strong><br />

& Ch 9). Yi Peng, ms (Vol 1, Chs 1 & 2; Vol 2, Précis & Ch 6). Yang Qiu, ms (Vol 1, Ch 8). Tricia Roberts, ms (Vol 1,<br />

Ch 4; Vol 2, Précis & Chs 1, 6, 8; g tables). Melissa Skeans, ms (Vol 2, Précis, hp<strong>2010</strong>, Chs 3 & 7; e & f tables).<br />

Craig Solid, ms (entire adr). Changchun Wang, ms (Vol 1, Précis & Chs 1, 2, 3, & 7; Vol 2, hp<strong>2010</strong> & Ch<br />

10). Eric Weinhandl, ms (Vol 1, Ch 5; Vol 2, Chs 5, 9, 10). David Zaun, ms (Vol 1, Ch 7; Vol 2, Chs<br />

3, 5, 10). information systems & software development for all chapters, with additional work as<br />

noted: Cheryl Arko, ba. Shu-Cheng Chen, ms (Vol 2, Précis; Chs 4 & 8; d tables). Frederick<br />

Dalleska, ms (Vol 2, Précis, Ch 10; i tables). Frank Daniels, bs. James Ebben,<br />

bs (Vol 1, Ch 9; Vol 2, Précis & Ch 11; k tables). Eric Frazier, bs (Vol 2, Précis,<br />

hp<strong>2010</strong>, Chs 1, 2, 3, 4, 8; a, b, c, m tables). Christopher Hanzlik, bs.<br />

Roger Johnson. C Daniel Sheets, bs. Xinyue Wang, ba/bs.<br />

disclosures for potential confl icts of interest<br />

funding & chapter contributors<br />

Allan Collins, MD, FACP Consultant/honoraria:<br />

Amgen, Baxter, NxStage, Sigma-<br />

Tau, Takeda. Robert Foley, MB, MSc Consultant/honoraria:<br />

21st Services, Amgen, Luitpold, Medscape, Merck, Novartis, Ortho,<br />

Vifor Pharma. David Gilbertson, PhD Consultant/honoraria: Amgen, DaVita<br />

Clinical Services. Charles Herzog, MD Consultant/honoraria: Amgen, CorMedix,<br />

������������������������������������������������������������������������������������<br />

Cambridge Heart, Merck. Bertram Kasiske, MD Consultant/honoraria: Litholink. Kirsten Johansen,<br />

MD Consultant/honoraria: Amgen. Research support (non-salary): Abbott, Amgen. Anne<br />

Murray, MD, MSc Equity ownership: Medtronic. Jon Snyder, PhD Consultant/Honoraria: Genzyme<br />

Transplant. Also, mmrf as an institution has separate contracts to conduct other, independent research funded<br />

by 21st Services, amag Pharmaceuticals, Amgen, Baxter, Bristol-Myers Squibb, DaVita, Fresenius, the Centers for<br />

Disease Control and Prevention, Genzyme, Merck/Schering-Plough, Mitsubishi Tanabe Pharma America, the National<br />

Institute on Aging / National Institutes of Health, the National Kidney Foundation, NxStage, Ortho-McNeil-Janssen,<br />

Satellite Healthcare, Shire, Sigma-Tau, and Takeda.<br />

This 22nd annual report of the <strong>United</strong> <strong>States</strong> <strong>Renal</strong> <strong>Data</strong> <strong>System</strong> is produced by the usrds Coordinating Center, operated<br />

under nih contract hhsn 267 2007 15002c / no1-dk-7-5002 by the Minneapolis Medical Research Foundation.<br />

������������������������������������u.s. <strong>Renal</strong> <strong>Data</strong> <strong>System</strong>, usrds <strong>2010</strong> Annual <strong>Data</strong> Report: Atlas of Chronic Kidney Disease<br />

and End-Stage <strong>Renal</strong> Disease in the <strong>United</strong> <strong>States</strong>, National Institutes of Health, National Institute of Diabetes and Digestive and<br />

Kidney Diseases, Bethesda, md, <strong>2010</strong>. ���������������������������������������������������������������������������������<br />

�������������������������������������� The data reported here have been supplied by the <strong>United</strong> <strong>States</strong> <strong>Renal</strong> <strong>Data</strong> <strong>System</strong> (usrds).<br />

���������������������������������������������������������������������������������������������������������������������������������������������������<br />

pretation of the U.S. government. �� ��������������� In titles, the superscript number or letter refers to the chapter, the following number<br />

�������������������������������������������������������������������������������������������������������������������������������������������������<br />

volume by periods — i.e., 3.1.ii refers to Chapter Three, Figure 1, Volume Two.


Upon the mountain’s edge with light touch resting,<br />

There a brief while the globe of splendour sits<br />

And seems a creature of the earth, but soon,<br />

More changeful than the Moon,<br />

To wane fantastic his great orb submits,<br />

Or cone or mow o����������������������owly<br />

Even to a star at length he lessons wholly.<br />

Samuel Taylor Coleridge<br />

“A Sunset”<br />

page<br />

5


<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

���<br />

ckd<br />

page 6<br />

at www.usrds.org<br />

pdf�������������<strong>2010</strong> adr�����������&���������������������������������������������������<br />

adr��gures &���������&����������������������������g����������������������������������������-<br />

������������� render�������������������������������������������g usrds��������������������-<br />

�����������������������g���������������usrds ��������g��������������adr��gures &��������<br />

new to this edition of the annual data report<br />

������������������������������������������������������������������������������esrd����������g������<br />

������������������g������������������g������������������������������&���������������������������������-<br />

�������������g�����������������ckd & esrd�������������������g��g���������������������������������������<br />

�����������������������������������������������������������������������g�����������������������������������������<br />

�������������������bmi &�����������������������������g����������������������g��������������������������������������<br />

������������������esrd����������&���������������������������������������������������������������������u.s. &��������<br />

�������������������������������esrd����������&�����g�����������������


Volume<br />

One CKD<br />

��������������� 8<br />

in���������n����<br />

����m���n� 12<br />

��������������������������ckd<br />

�������������������� 17<br />

1 ckd����������������<br />

���������� 39<br />

2 ckd������������������<br />

����������� 53<br />

3 ����������������������ckd 65<br />

4 ����������&���������� 77<br />

5 ��������������������������<br />

��������������ckd 87<br />

6 ���������������������������<br />

���������������������<br />

��������������ckd 99<br />

7 ������������������esrd 109<br />

8 ������������������� 121<br />

9 ���������ckd 133<br />

���������������� 145<br />

����������<br />

������������������������������� 1644<br />

����������<br />

usrds ���������&��������� 174<br />

�������� 180<br />

����� 185<br />

������������� 174<br />

������������������men� 183<br />

Volume<br />

Two ESRD<br />

���������������� 196<br />

in���m����n�m��� 198<br />

������m���mm����&��������������� 200<br />

in���������n��������m������ 202<br />

��������������������������esrd<br />

��������������������� 209<br />

����������������������<strong>2010</strong> 223<br />

1�� ���������������� 239<br />

2�� ����������&������������ 253<br />

3�� ������������������������ 267<br />

4�� ��������������������� 277<br />

5�� ��������������������&������������������� 287<br />

6�� ����������&����������� 301<br />

7�� ��������������� 311<br />

8�� ����������esrd 325<br />

9�� ���������������� 335<br />

10������������ 353<br />

11�� ���������esrd 367<br />

12���������������������������� 383<br />

����������������� 397<br />

������������������������������������������� 462<br />

���������� usrds����������&���������� 494<br />

��������� 500<br />

cms������� 507<br />

������ 521<br />

�������������� 524<br />

��������� 526<br />

�������������� 494<br />

������������������men�� 503<br />

in���n����n�����������������n����m� 505<br />

page<br />

7


<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

���<br />

ckd<br />

page 8<br />

Volume<br />

One CKD<br />

����������������������������������������������������������������������� 17<br />

summary statistics; awareness, treatment, & control; patient characteristics; prescription drug<br />

therapy; hospitalization & mortality; cardiovascular disease; the transition zone in nursing<br />

home patients; the transition to ESRD; acute kidney injury; costs of CKD<br />

������������������������������������������������������ 39<br />

strategies for identifying CKD; comorbidity burden; clinical & biochemical abnormalities;<br />

awareness, treatment, & control of disease conditions; predictive models for CKD; mortality<br />

��������������������������������������������������������� 53<br />

incidence & prevalence of recognized CKD; CKD as defined by the new diagnosis codes;<br />

comorbidity burden in patients with CKD; describing CKD through laboratory values<br />

���������������������������������������������������� 65<br />

identified CKD & physician follow-up; laboratory evaluations; prescription drug therapy;<br />

biochemical levels & drug therapy<br />

Volume<br />

Two ESRD<br />

������������������������������������������������������������������������ 209<br />

trends in patient counts & spending; modalities; quality of care; hospitalization & mortality;<br />

expenditures<br />

������������������� � 223<br />

incident rates; cardiovascular disease; counseling prior to ESRD; fistula use; transplantation;<br />

diabetes; care of patients with CKD & diabetes; urine microalbumin measurements;<br />

vaccinations; network achievement of HP<strong>2010</strong> objectives<br />

�������������������������������������������������������� 239<br />

all-cause & cause-specific hospital admissions; hospitalizations for vascular access infection;<br />

outpatient antibiotic use; infectious hospitalization & antibiotic use; mortality & antibiotic use<br />

��������������&������������� 253<br />

incidence; prevalence; incident rates & racial differences; rare diseases; network populations<br />

������������������������������ 267<br />

patient care prior to initiation; anemia & treatment; laboratory values at initiation; transplant<br />

options; wait list & transplantation<br />

��������������������������� 277<br />

incident modality; prevalent modality; home hemodialysis; introduction to Part D<br />

������������������������&�������������������� 287<br />

anemia treatment & hemoglobin control; preventive care; vascular access in prevalent patients;<br />

overview of Medicare Part D use


���������������&������������ 77<br />

hospitalization rates in CKD & non-CKD patients; infectious hospitalizations; mortality rates<br />

�������������������������������������������������������������������� 87<br />

prescription drug therapy; survival & hospitalization; prevalent disease states;<br />

treatment for heart disease<br />

������������������������������������������������������������������ckd � 99<br />

cognitive function; physical function; mortality<br />

������������������������������������������������� 109<br />

patient care & laboratory testing prior to ESRD; prescription drug therapy & medication<br />

continuity in the transition to ESRD<br />

��������������������������� 121<br />

characteristics of patients with AKI; overall hazard & adjusted rates of AKI; patient care &<br />

outcomes following AKI hospitalization<br />

�������������������������������������� 133<br />

overall costs; components of costs; Medicare Part D costs; CKD costs in the U.S. & Taiwan<br />

��������������������� � 145<br />

��������������&������������ 301<br />

overall hospitalization; outcomes; hemodialysis matched to peritoneal dialysis;<br />

cause-specific hospitalization & mortality<br />

����������������������� 311<br />

kidney transplant wait list; kidney donation & transplantation; transplant discharge<br />

& follow-up; transplant outcomes; transfusions & panel-reactive antibodies<br />

����������������������������������������� 325<br />

patient counts; preventive care & hospitalization; first-year hospitalization & mortality<br />

���������������������� 335<br />

cardiovascular special studies; rehabilitation & quality of life special studies;<br />

nutrition special studies<br />

��������������� 353<br />

provider growth; anemia treatment; clinical monitoring; preventive care;<br />

costs for interventions & preventive care; vascular access & fluid overload<br />

hospitalizations; standardized hospitalization & mortality ratios<br />

����������������������������������������� 367<br />

overall costs of ESRD; costs overall & for injectables & vascular access; racial differences<br />

in costs; costs in matched & unmatched dialysis populations; Medicare Part D costs<br />

���������������������������������� 383<br />

incidence & prevalence of ESRD; dialysis; transplantation;<br />

incident ESRD rates in Asian & indigenous populations<br />

���������������������� � 397<br />

page<br />

9


<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

��� ckd<br />

page<br />

��<br />

�����i�� CKD �vol 1�� C�a�ter 6<br />

P������i��s NHANES CKD �vol 1�� C�a�ter 1 new patients CKD �vol 1�� 2.2, 2.4–6, 2.10–13; ESRD<br />

CKD �vol 1�� 9.18–23; ESRD �vol 2�� C�a�ter 12 C�g�i�i�e�<br />

�vol 1� 2.a pediatric patients ESRD �vol 2�� C�a�ter 8 international comparisons;<br />

2.7–9, 2.14–17; ESRD �vol 2�� �.1–3, �.7, C�a�ter 2, 4.2, 4.b–8, 8.1, 8.5–7 CKD datasets<br />

�vol 2�� �.a–4, �.7, ��.2, C�a�ter 2, 4.1, 4.a–5, 8.1–4 existing patients CKD �vol 1�� C�a�ter 1, 2.3,<br />

& E S<br />

THE�<strong>2010</strong>�ANNUAL�DATA�REPORT�<br />

A E S I D Y E N D I K C I N O<br />

IN�<br />

R<br />

ON�<br />

H C<br />

I AT<br />

F O<br />

M R<br />

S<br />

O<br />

A<br />

F<br />

L<br />

N I<br />

T A<br />

T�e���e��� preventive care ESRD �vol 2��<br />

antibiotics ESRD �vol 2�� 1.15–21, 1.25–33 awareness/treatment/control<br />

��.21–� 5.10–16, 8.8–9, 10.13–18 drug therapy CKD<br />

�vol 1�� 3.27–24, 5.a–5, 5.13–19, 7.13–a ESRD �vol2�� 5.24–40<br />

C�a�ters 4 & 7 laboratory values & testing CKD �vol 1�� 1.�–9, 2.c–26, 3.9–16, 7.7–12; ESRD �vol 2�� 3.b–13<br />

�vol 2�� 5.1 dialysis access ESRD �vol 2�� 3.1, 3.2–4, 5.17–23 transplantation �vol 2� �.6, ��.14–17,<br />

physician care CKD �vol 1�� 3.2–8, 7.2–6; ESRD �vol 2�� 3.2–a KDOQI guidelines ESRD<br />

CKD �vol 1�� 1.e–13, 3.25–28 anemia treatment ESRD �vol 2�� 3.5–7, 5.2–9


PA � F O � S RTI<br />

C I P O<br />

R E G A T S -<br />

T<br />

E<br />

D<br />

N<br />

N<br />

A<br />

E<br />

CULAR�<br />

L I D<br />

INTEREST<br />

SEA SE IN THE U. S.<br />

Dise�ses identifying CKD �vol 1�� 1.a–4, 2.10–17 anemia ESRD �vol 2�� 3.5–7, 5.2–9 cardiovascular disease<br />

CKD �vol 1�� 1.c–8, 3.15, C�a�ter 5; ESRD �vol 2�� ��.5, 6.15, 9.2–14 diabetes CKD �vol 1��<br />

C�a�ter 1, 2.12.b–18; ESRD �vol 2�� ��.18–21, 2.7, 2.15, 5.10–13, 6.7, 10.13–15 acute kidney<br />

injury �vol 1� C�a�ter 8 Medi���e�P����D CKD �vol 1�� 9.12–17; ESRD �vol 2��<br />

4.12–e, 5.24–40, 11.47–59 C�s�s CKD �vol 1�� C�a�ter 9; ESRD �vol 2��<br />

�.20–28, C�a�ter 11<br />

O�����es hospitalization<br />

CKD �vol 1��<br />

C�a�ter 4, 5.7–8; ESRD �vol 2�� �.16, 1.1–14, 1.22–24,<br />

C�a�ter 6, 8.10–15 mortality CKD �vol 1��, 1.18–21, 4.16–19;<br />

ESRD �vol 2�� �.17–18, C�a�ter 6, 8.16–18 survival CKD �vol 1�� 5.6;<br />

ESRD �vol 2�� �.19, 6.7, 8.19 D���������sis analytical methods �A��en��x A�<br />

CKD �vol 1�� �� 164; ESRD �vol 2�� �� 462 data � les available to researchers �A��en��x B�<br />

�� 174 �vol 1�, �� 494 �vol 2� agreement for release of data �� 183 �vol 1�, �� 503 �vol 2�<br />

page<br />

��


<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

��� ckd<br />

page<br />

��<br />

disease (CKD), defining its burden in the general population, and looking<br />

a surveillance<br />

system coordinated<br />

by the National<br />

Center for Health Statistics at<br />

at cardiovascular and other comorbidities, adverse events, preventive the Centers for Disease Control and<br />

care, prescription medication therapy, care during the transition Prevention. The conceptual model of this<br />

to ESRD, and costs to Medicare and employer group health system was based on similar approaches for<br />

plans. In Volume Two we provide information on the size populations at risk for diabetes and hypertension,<br />

and impact of the end-stage renal disease (ESRD) popu- two well-known diseases that damage the kidney as<br />

lation — the traditional focus of the <strong>USRDS</strong> — pre- well as other organ systems. The model characterizes<br />

senting an overview of the ESRD program, along progressive stages of CKD, from early evidence of kidney<br />

with detailed data on incidence, prevalence, damage — such as albumin in the urine — to overt reductions<br />

comorbidity of new ESRD patients, severity in the filtering capacity of the kidney, defined by the estimated<br />

of disease, clinical care, hospitalization and glomerular filtration rate (eGFR).<br />

mortality rates, pediatric patients, renal There are many issues related to defining the levels of eGFR and<br />

transplantation, the provider delivery urine albumin which indicate “true disease” in the kidney during the<br />

system, and the economics of the early stages of CKD, as compared to a normal reduction in kidney fil-<br />

ESRD program.<br />

tering capacity, particularly in the elderly. A new estimating equation was<br />

We approach Volume One published in the Annals of Internal Medicine in May, 2009, improving on<br />

from the perspective that the the MDRD method; we compare these two equations, providing a perspective<br />

implications of CKD were un- for readers on the strengths and weaknesses of each. The <strong>USRDS</strong> and others will<br />

der-appreciated prior to Feb- continue to investigate these issues in both the clinical and public health arenas,<br />

ruary, 2002, when a new but already there is important data available on the impact of CKD, data based not<br />

CKD classification staging only on biochemical information, but on the disease as defined within the Medicare<br />

system was proposed. and health plan datasets. The impact of the CKD staging system as a predictor of mor-<br />

The five-stage system bidity and mortality is now well known on a population level, but its translation into<br />

was developed using the care of individual patients is another matter.<br />

population-level data The 2008 ADR was the first to include a volume dedicated to CKD; this year we expand<br />

from the National the volume to ten chapters, including an analysis of acute kidney injury as well as a chapter<br />

Health and Nutri- on cardiovascular disease. New this year is a chapter on the transition between CKD and<br />

tion Examination ESRD in nursing home patients, and analyses of medication use under the Part D prescrip-<br />

Survey (NHANES), tion drug benefit, which began in 2006.<br />

j ����������������������������������������������������������������<br />

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�����������������������������������������������������<br />

introduction to volume one � ckd


In the Précis we highlight some of the most<br />

important data from the chapters, and address<br />

the burden of CKD — an area of major public policy<br />

and health concern. In Chapter One we then define<br />

the CKD population, using NHANES cohorts over a 20year<br />

period, and looking at the burden of chronic conditions<br />

such as diabetes and cardiovascular disease. We also<br />

compare CKD populations identified through the MDRD<br />

and CKD-EPI equations, and address the degree of biochemical<br />

and clinical abnormalities. We conclude with analyses of<br />

awareness, treatment, and control of cardiovascular risk factors,<br />

and an assessment of mortality rates by eGFR, race, and gender.<br />

Basic descriptive and comorbidity information from the major<br />

datasets used by the <strong>USRDS</strong> — the 5 percent Medicare sample,<br />

and the MarketScan and Ingenix i3 databases — is summarized in<br />

Chapter Two. We use laboratory data from the Ingenix i3 LabRx dataset<br />

to define, by CKD stage, levels of typical biochemical parameters.<br />

Remarkably, the abnormalities identified here are quite similar to<br />

those in the NHANES population-level data. We also demonstrate the<br />

consistency of the relationship between CKD defined from actual laboratory<br />

data and that reported by diagnosis codes on claims for services.<br />

In Chapter Three we address the care of patients with CKD, looking<br />

at the likelihood of urine microalbumin testing based on diabetic and<br />

hypertensive status. Testing rates are surprisingly low, particularly<br />

among patients with hypertension — known for its associated risk of<br />

kidney disease. We then report on the use of prescription medications,<br />

including ACEIs/ARBs, beta blockers, calcium channel blockers, lipid<br />

lowering agents, diuretics, ESAs, oral Vitamin D, and phosphate binders,<br />

and examine the degree of lipid and glycemic control.<br />

Hospitalization and mortality across chronic disease conditions<br />

are examined in Chapter Four, along with hospitalizations for<br />

pneumonia, bacteremia/sepsis, and urinary tract infections, and<br />

trends in adjusted rates of mortality. Although increased recognition<br />

of kidney disease can bias the patient cohort over time,<br />

adjustments for severity of disease help reduce this bias, and<br />

demonstrate that survival has improved.<br />

Cardiovascular disease in the CKD population is the focus<br />

of Chapter Five, in which we evaluate, by CKD stage, major<br />

cardiovascular diagnoses and interventions, medication<br />

use, survival, and hospitalization.<br />

Chapter Six addresses the transition to ESRD in the<br />

institutionalized elderly entering nursing homes,<br />

using data from the Medicare Minimum <strong>Data</strong> Set.<br />

We first compare general nursing home patients<br />

to those with CKD and ESRD, then examine how<br />

memory, decision making, and the ability to make oneself<br />

understood change over time after admission to a<br />

nursing home. We also look at physical function in the<br />

non-CKD, CKD, and ESRD populations, and conclude<br />

with analyses of survival.<br />

Chapter Seven addresses the transition from<br />

CKD to ESRD, a period of great concern, and one<br />

which may contribute to high mortality in the<br />

first months on dialysis. We illustrate the time-<br />

line for recognition of CKD prior to ESRD, and<br />

present data on visits to primary care physicians<br />

and to specialists among patients<br />

who reach ESRD, assessing when providers<br />

begin to recognize the trajectory of the<br />

disease in this vulnerable population.<br />

In Chapter Eight we continue our<br />

analysis of acute kidney injury (AKI)<br />

and its relationship to CKD and ESRD.<br />

Recognized AKI has been increasing<br />

in both the Medicare and the younger<br />

EGHP populations. We examine the<br />

type of dialysis used, if any, and the<br />

underlying diagnoses. We then look<br />

at follow-up after discharge, determining<br />

which physicians see these patients<br />

and what role nephrologists play<br />

in the first year after AKI. We have also<br />

added data on medication use and on<br />

rehospitalization for AKI.<br />

We conclude with Chapter Nine, addressing<br />

the costs associated with CKD,<br />

and introducing new analyses comparing<br />

costs in the U.S. and Taiwan. We also present<br />

data on prescription drug costs in 2007<br />

under the new Part D benefit.<br />

<strong>Data</strong> presented in this volume illustrate<br />

the challenges that CKD, its complications,<br />

and its costs pose to the healthcare system<br />

and to policy makers. Programs to detect CKD<br />

have been initiated by the CDC, and the National<br />

Kidney Foundation’s Kidney Early Evaluation<br />

Program (KEEP) has been ongoing since 2000. By<br />

their nature, detection programs are broad-based approaches<br />

to define, through the use of simple tests, populations<br />

at risk of a disease or its complications, targeting<br />

continued on page 16<br />

page<br />

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<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

��� ckd<br />

page<br />

��<br />

I ai<br />

I 1i<br />

<strong>USRDS</strong><br />

contacts<br />

Centers for<br />

Medicare &<br />

Medicaid Services<br />

External<br />

Advisory<br />

Committee<br />

Co-Project Offi cer, <strong>USRDS</strong><br />

Lawrence Y.C. Agodoa, MD<br />

NIDDK<br />

2 Democracy, Room 653<br />

6707 Democracy Blvd<br />

Bethesda, MD 20892-5454<br />

Phone 301.594.1932<br />

Fax 301.594.9358<br />

agodoal@extra.niddk.nih.gov<br />

Co-Project Offi cer, <strong>USRDS</strong><br />

Paul W. Eggers, PhD<br />

NIDDK<br />

2 Democracy, Room 615<br />

6707 Democracy Blvd<br />

Bethesda, MD 20892-5454<br />

Phone 301.594.8305<br />

Fax 301.480.3510<br />

eggersp@extra.niddk.nih.gov<br />

CC data requests<br />

612.347.7776 or<br />

1.888.99<strong>USRDS</strong>;<br />

usrds@usrds.org<br />

CC data fi les<br />

Shu-Cheng Chen, MS, MPH<br />

schen@usrds.org<br />

Website, RenDER<br />

Eric Frazier, BS<br />

Stephan Dunning, MGIS<br />

webmaster@usrds.org<br />

Administrative<br />

oversight of the <strong>USRDS</strong><br />

National Institutes<br />

of Health (NIH)<br />

National Institute of<br />

Diabetes & Digestive &<br />

Kidney Diseases (NIDDK)<br />

Division of Kidney,<br />

Urologic, & Hematologic<br />

Diseases (DKUHD)<br />

Project<br />

Officers<br />

Steering<br />

Committee<br />

<strong>USRDS</strong><br />

Coordinating Center<br />

<strong>USRDS</strong> Coordinating<br />

Center (CC)<br />

914 South 8th Street<br />

Suite S-206<br />

Minneapolis, MN 55404<br />

Phone 612.347.7776<br />

Toll-free 1.888.99<strong>USRDS</strong><br />

Fax 612.347.5878<br />

www.usrds.org<br />

CC Director<br />

Allan J. Collins, MD, FACP<br />

acollins@usrds.org<br />

CC Deputy Director<br />

Robert N. Foley, MB, MSc<br />

rfoley@usrds.org<br />

Director, Cardiovascular<br />

Special Studies Center (SSC)<br />

Charles Herzog, MD<br />

cherzog@usrds.org<br />

Director, Nutrition SSC<br />

Kirsten Johansen, MD<br />

Kirsten.Johansen@ucsf.edu<br />

Director,<br />

Rehabilitation &<br />

Quality of Life SSC<br />

Nancy Kutner, PhD<br />

nkutner@emory.edu<br />

<strong>Data</strong> Request Review Committee<br />

Special Studies Review &<br />

Implementation Committee<br />

<strong>Renal</strong> Community Council<br />

<strong>USRDS</strong> Special<br />

Studies Centers<br />

Director<br />

Allan Collins, MD<br />

Deputy Director<br />

Robert Foley, MB, MSc<br />

<strong>Data</strong> management,<br />

computer systems,<br />

& quality<br />

Shu-Cheng Chen, MS<br />

Co-investigators ADR editorial<br />

production<br />

Susan Everson, PhD<br />

Epidemiology<br />

Robert Foley, MB, MSc<br />

Areef Ishani, MD, MS<br />

Marshall McBean,<br />

MD, MSc<br />

Jon Snyder, PhD<br />

Cardiovascular<br />

Special Studies<br />

Charles Herzog, MD<br />

Director<br />

Blanche Chavers, MD<br />

Deputy Director<br />

Robert Foley, MB, MSc<br />

Co-investigator<br />

David Gilbertson, PhD<br />

Shuling Li, MS<br />

Craig Solid, MS<br />

Biostatistics<br />

Rehabilitation & Quality<br />

of Life Special Studies<br />

Nancy Kutner, PhD<br />

Director<br />

Kirsten Johansen, MD<br />

Deputy Director<br />

Haimanot Wasse, MD<br />

Nephrology<br />

introduction to volume one � ckd<br />

I 2i<br />

I bi<br />

Departmental organization<br />

of the Coordinating Center<br />

Medicine<br />

Blanche Chavers, MD<br />

Charles Herzog, MD<br />

Bertram Kasiske, MD<br />

Anne Murray, MD, MSc<br />

Wendy St. Peter, PharmD<br />

Departmental organization<br />

of the Special Studies Centers<br />

Business operations<br />

Minneapolis Medical<br />

Research Foundation<br />

Kim Miller<br />

Health policy<br />

& economics<br />

Suying Li, PhD<br />

Lih-Wen Mau, PhD<br />

Biostatistics<br />

David Gilbertson, PhD<br />

Jiannong Liu, PhD<br />

Eric Weinhandl, MS<br />

Nutrition<br />

Special Studies<br />

Kirsten Johansen, MD<br />

Director<br />

George Kaysen, MD, PhD<br />

Deputy Director<br />

Glenn Chertow, MD, MPH<br />

Manjula Tamura, MD<br />

Stefanos Zenios, MD<br />

Co-Investigators<br />

Barbara Grimes<br />

Su-Chun Chen, DSc<br />

Charles McCulloch, PhD<br />

Epidemiology & Biostatistics<br />

Yijian Huang, PhD<br />

Rebecca Zhang, MS<br />

Biostatistics<br />

Tess Bowles, MEd<br />

Research Coordinator


I 3i<br />

I ci<br />

Structure of the<br />

<strong>USRDS</strong> database<br />

CMS<br />

PMMIS/<br />

REBUS/REMIS<br />

ESRD<br />

cohort<br />

finder files<br />

CMS ESRD Part A SAF<br />

claims: OP, IP,<br />

SNF, HH, hospice<br />

Common Standard Re-usable Working Set Library<br />

<strong>USRDS</strong><br />

members<br />

Patient<br />

profile<br />

Modality/<br />

payor<br />

sequence<br />

<strong>USRDS</strong> Annual<br />

<strong>Data</strong> Report<br />

National Institute of Diabetes<br />

& Digestive & Kidney Diseases (NIDDK)<br />

Robert Star, MD<br />

Director, Division of Kidney, Urologic,<br />

& Hematologic Diseases (DKUHD)<br />

Lawrence Y.C. Agodoa, MD<br />

Co-Project Offi cer, <strong>USRDS</strong>; Director,<br />

End-Stage <strong>Renal</strong> Disease Program<br />

CMS ESRD Part B SAF<br />

claims: Physician/<br />

Supplier, DME<br />

Comorbidity<br />

profile<br />

Paul W. Eggers, PhD<br />

Co-Project Offi cer, <strong>USRDS</strong>; Program Director,<br />

Kidney & Urology Epidemiology<br />

April Merriwether<br />

Contract Specialist, NIH/NIDDK<br />

Centers for Medicare<br />

& Medicaid Services (CMS)<br />

Diane L. Frankenfi eld, DrPH<br />

Senior Research Analyst, Division of Research<br />

on Health Plans & Drugs (DRHPD), Research<br />

& Evaluation Group, Offi ce of Research,<br />

Development, & Information (ORDI)<br />

Mary Teresa Casey, RD, LD<br />

Manager, ESRD Network Program, & Director,<br />

Division of Quality Improvement Policy for<br />

Chronic and Ambulatory Care (DQIPCAC),<br />

Quality Improvement Group, Offi ce of Clinical<br />

Standards and Quality (OCSQ)<br />

Barry Straube, MD<br />

CMS Chief Medical Offi cer & Director, OCSQ<br />

Debbie Hattery<br />

Director, Information <strong>System</strong> Group, OCSQ<br />

<strong>USRDS</strong> researcher<br />

SAF CDs<br />

5% general Medicare SAF<br />

claims: OP, IP, SNF, HH, hospice,<br />

Physician/Supplier, DME<br />

<strong>USRDS</strong> database<br />

(2.1 million patients)<br />

Tx<br />

profile<br />

<strong>Data</strong><br />

analyses<br />

CMS ESRD & 5% general<br />

Medicare Claims data:<br />

Part A, Part B, & EPO<br />

<strong>USRDS</strong> custom<br />

data files<br />

UNOS<br />

tx<br />

data<br />

<strong>USRDS</strong> Coordinating Center (CC) &<br />

Special Studies Centers (SSCs)<br />

Allan J. Collins, MD, FACP<br />

CC Director; Professor of Medicine, University<br />

of Minnesota (U of MN) School of Medicine;<br />

Nephrologist, Department of Medicine,<br />

Hennepin County Medical Center (HCMC)<br />

Robert Foley, MB, MSc<br />

CC Deputy Director;<br />

Associate Professor of Medicine,<br />

U of MN School of Medicine<br />

Ingenix i3<br />

& MarketScan<br />

enrollment<br />

& claims data<br />

UNOS<br />

transplant<br />

data<br />

<strong>USRDS</strong> web-based<br />

applications<br />

Charles Herzog, MD<br />

Director, Cardiovascular SSC;<br />

Staff Cardiologist, Department of Medicine, HCMC;<br />

Professor of Medicine, U of MN School of Medicine<br />

Kirsten Johansen, MD<br />

Director, Nutrition Special Studies Center;<br />

Associate Professor in Residence, Nephrology,<br />

University of California at San Francisco<br />

Nancy Kutner, PhD<br />

Director, Rehabilitation &<br />

Quality of Life Special Studies Center;<br />

Professor of Rehabilitation Medicine,<br />

Emory University Medical School<br />

<strong>USRDS</strong> CC Co-Investigators<br />

Blanche Chavers, MD<br />

Professor of Pediatrics,<br />

U of MN School of Medicine<br />

David Gilbertson, PhD<br />

Director, Epidemiology & Biostatistics, <strong>USRDS</strong><br />

CMS<br />

EPO<br />

data<br />

<strong>USRDS</strong> Special<br />

Studies data<br />

CMS<br />

ESRD<br />

facility<br />

data<br />

CDC<br />

survey<br />

data<br />

Disease-specific<br />

cohort finder files<br />

(CKD, CHF, DM)<br />

NHANES<br />

Network<br />

SIMS<br />

EGHP claims<br />

data:<br />

Parts A & B<br />

Charles Herzog, MD<br />

Staff Cardiologist, Department of Medicine, HCMC;<br />

Professor of Medicine, U of MN School of Medicine<br />

Areef Ishani, MD, MS<br />

Clinical Scholar, Center for Epidemiology & Clinical<br />

Research; Assistant Professor of Medicine, VA<br />

Medical Center (Minneapolis) & U of MN School<br />

of Medicine<br />

Bertram Kasiske, MD<br />

Professor of Medicine, U of MN School of Medicine;<br />

Chief of Nephrology, Department of Medicine,<br />

HCMC<br />

Suying Li, PhD<br />

Health policy, <strong>USRDS</strong><br />

Jiannong Liu, PhD<br />

Biostatistics, <strong>USRDS</strong><br />

Lih-Wen Mau, PhD<br />

Health policy, <strong>USRDS</strong><br />

Marshall McBean, MD, MSc<br />

Professor & Department Head,<br />

Department of Health Management & Policy,<br />

U of MN School of Public Health<br />

Anne Murray, MD, MSc<br />

Associate Professor of Medicine,<br />

U of MN School of Medicine;<br />

Staff Geriatrician, HCMC<br />

Wendy St. Peter, PharmD, BCPS<br />

Professor, U of MN College of Pharmacy;<br />

Department of Medicine, HCMC<br />

Jon Snyder, PhD<br />

Epidemiology, <strong>USRDS</strong>; Adjunct Assistant Professor,<br />

U of MN School of Public Health<br />

page<br />

��


<strong>2010</strong><br />

usrds<br />

annual<br />

data<br />

report<br />

volume<br />

��� ckd<br />

page<br />

��<br />

individuals for detailed evaluation and intervention.<br />

The data we present here indicate that the CKD population<br />

is under-recognized, and that care of both<br />

the CKD population as a whole and of those patients<br />

transitioning to ESRD is less than optimal; both issues<br />

may contribute to the increased morbidity and<br />

mortality of this high-risk population.<br />

The CKD education benefit for Medicare patients<br />

begins in 2011, with the intent to improve access<br />

to care, modality selection, consideration of home<br />

therapies, access to preemptive transplant, planned<br />

vascular access, management of risk factors, and referral<br />

to nephrologists and nutritional counseling.<br />

We plan to follow trends in these key aspects of care<br />

to determine the impact of this new benefit, and<br />

to examine how it might affect the high first-year<br />

mortality among hemodialysis patients.<br />

The <strong>USRDS</strong> website, Researcher’s Guide, database,<br />

and administrative oversight are described in the<br />

introduction to Volume Two.<br />

Maps in the ADR present data divided into quintiles.<br />

In the sample map, for example, approximately<br />

one-fifth of all data points have a value of<br />

10.8 or above. Ranges include the number at the<br />

lower end of the range, and exclude that at the upper<br />

end (i.e, the second range here is 8.2–

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