The number of new patients starting end-stage renal disease (ESRD) therapy and initiating therapy on hemodialysis (HD) declined from 2010 to 2011, the most recent year for which data are available, according to the recently released 2013 Annual Data Report from the U.S. Renal Data System (USRDS).

In 2011, 115,643 patients started ESRD therapy, down from 116,946 in 2010, and 101,683 patients started HD, a decrease from 103,874 in 2010.

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In addition, the population starting peritoneal dialysis (PD) grew for the third consecutive year, and now makes up 6.6% of patients with a known dialysis modality, the report stated. “The change is associated with the new bundled payment system, with its clear incentives for peritoneal dialysis,” the report said.

At the end of 2011, 430,273 patients were receiving dialysis and 185,626 patients were alive with a functioning kidney transplant, a 3.2% increase from 2010, according to the report.

Commenting on the new report, Joseph A. Vassalotti, MD, Chief Medical Officer for the National Kidney Foundation (NKF), said he can only speculate that enhanced management of the major chronic kidney failure causes—diabetes and hypertension—may have contributed to the decline in new ESRD cases. Encouragingly, he said, the decline in incident patients is occurring for the most part across racial groups and causes of ESRD.

Data also show than many patients starting renal replacement therapy (RRT) have never had a prior nephrology consult. In 2011, 42% of new ESRD patients had not seen a nephrologist prior to starting therapy.

“That is a stunning figure, which has not changed over recent reporting years,” Dr. Vassalotti, Associate Clinical Professor of Medicine at Mount Sinai Medicine Center in New York, told Renal & Urology News. “I think low use of nephrology services is difficult to attribute entirely to lack of access to care.”

Low awareness of CKD among patients and under-detection of kidney disease by practitioners may be one reason why so many ESRD patients do not have a nephrology consultation prior to starting RRT, he said.

Lastly, the use of hemodialysis (HD) catheters for incident patients is unacceptably high at nearly 80% in 2011, Dr. Vassalotti said. The duration of nephrology services prior to the onset of ESRD is clearly and consistently associated with lower catheter use at hemodialysis initiation, he said. According to the report, which was published as a supplement to the American Journal of Kidney Diseases, mortality rates in the ESRD and dialysis populations continue to decline, although they remain much higher than in the general population. The adjusted mortality rate among ESRD patients (per 1,000 patient years at risk) decreased from 351 in 1996 to 241 in 2011, a decline of 31.3%. During that same period, the adjusted mortality rate in the dialysis population dropped from 362 to 266, a decrease of 26.5%.

In 2011, among individuals aged 65 years or older, the adjusted mortality rate was 272.5 and 314.3 per 1,000 patient years at risk in the ESRD and dialysis populations, respectively, compared with 48 in the general population.

The adjusted first-year all-cause mortality rate from day 1 in 2010 was 254.4 per 1,000 patient years at risk, 268.8 for HD patients, 121.4 for PD patients, and 54.4 for kidney transplant patients (from the date of transplant). From day 90, the rate was 221.5 for HD patients and 126 for PD patients.

Dialysis patients overall in 2011 had an expected 6.2 years of remaining life, whereas the general population in 2009 had an expected 22.5 years of remaining life, USRDS data show. Kidney transplant recipients fared better than dialysis patients, with 17.2 years of expected life remaining in 2011. The difference in life expectancy between dialysis patients and their non-ESRD counterparts was larger in certain age groups. For example, in the age group 50-54 years, dialysis patients had an expected 7.1 years of remaining life in 2011 compared with 27.1 years in the general population in 2009.

In a preface to the report, the authors noted that rates of hospitalization for infection in the HD population are of particular concern. These rates increased 43% from 1993 to 2011. During the same period, rates of cardiovascular and all-cause hospitalization declined 7.3% and 3.0%, respectively. The adjusted infection hospital days per patient increased 19.2% for HD patients and decreased 19.4% and 25.2%, respectively, for patients on PD or with a kidney transplant.

In contrast, from 1993 to 2011, the infection, cardiovascular, and all-cause hospitalization rate decreased 1.8%, 21.9%, and 14%, respectively, for PD patients and 4.6%, 39.5%, and 15.7%, respectively, for kidney transplant recipients.

Regarding the increase in ESRD patient hospital admissions for infection, Dr. Vassalotti pointed out that a rise in the hospitalization rate could reflect the obvious and well-recognized problem of the use of hemodialysis catheters, particularly in the context of decreasing infectious hospitalization rates for PD and transplantation. The Fistula First Catheter Last quality improvement initiative of the Centers for Medicare and Medicaid Services is focusing on this problem through the ESRD networks.

Pneumonia is another contributing factor. In 2011, pneumonia admissions for HD and PD patients were 1.9 and 1.6 times higher, respectively, than rates in 1993. Some types of pneumonia are probably beyond the scope of dialysis clinic care, Dr. Vassalotti noted. However, pneumonia that complicates influenza infection and pneumococcal pneumonia may be prevented in the dialysis setting by the appropriate use of vaccinations.

The report also summarized data for chronic kidney disease (CKD), noting that it “is important for individuals at risk for CKD be screened periodically for kidney disease.” Urine albumin and creatinine are valuable laboratory markers for detecting early signs of kidney damage, the report noted, but data show that urine albumin and creatinine testing is underused. In 2011, the probability of urine albumin and creatinine testing was 36% and 87%, respectively, among patients with diabetes but not hypertension and 5% and 88%, respectively, among patients with hypertension but not diabetes. The rates were 37% and 93%, respectively, for patients with both diabetes and hypertension.

The NKF’s Kidney Disease Outcomes Quality Initiative work group led by Harold I. Feldman, MD, and Lesley A. Inker, MD, will soon publish a U.S. commentary on the 2012 Kidney Disease: Improving Global Outcomes (KDIGO) international Clinical Practice Guideline for the Evaluation and Management of CKD, Dr. Vassalotti said. The commentary will emphasize the role of estimated GFR using the 2009 CKD-EPI creatinine equation and the urinary albumin-creatinine ratio in testing, detection, assessment of prognosis, and management.