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 Table AHP2020 CKD Objectives
 Table 3.1CKD-3 Increase the proportion of hospital patients who incurred acute kidney injury who have follow-up renal evaluation in 6 months post discharge: Target 12.3%
 Table 3.2D-12 Increase the proportion of persons with diagnosed diabetes who obtain an annual urinary microalbumin measurement: Target 37.0%
 Table 3.3CKD-4.1 Increase the proportion of persons with chronic kidney disease who receive medical evaluation with serum creatinine, lipids, and microalbuminuria: Target 28.4%
 Table 3.4CKD-4.2 Increase the proportion of persons with type 1 or type 2 diabetes and chronic kidney disease who receive medical evaluation with serum creatinine, microalbuminuria, A1c, lipids, and eye examinations: Target 25.3%
 Table 3.5CKD-5 Increase the proportion of persons with diabetes and chronic kidney disease who receive recommended medical treatment with angiotensin-convertingenzyme inhibitors or angiotensinII receptor blockers: Target 76.3%
 Table 3.6CKD-8 Reduce the rate of new cases of end-stage renal disease (ESRD): Target 352.0 new cases per million population
 Table 3.7CKD-9.1 Reduce kidney failure (or end-stage renal disease, ESRD) due to diabetes: Target 154.4 per million population
 Table 3.8CKD-9.2 Reduce kidney failure (or end-stage renal disease, ESRD)due to diabetes among persons with diabetes: Target 2,354.4 per million population
 Table 3.9CKD-10 Increase the proportion of chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy: Target 30.0%
 Figure 3.1CKD-10 Geographic distribution of the adjusted proportion of chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy, by state, in the U.S. population, 2015: Target 30.0%
 Table 3.10CKD-11.1: Increase the proportion of adult hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access: Previous data source target 50.6%
 Table 3.11CKD-11.2: Reduce the proportion of adult hemodialysis patients who use catheters as the only mode of vascular access: Previous data source target 26.1%
 Table 3.12CKD-11.3 Increase the proportion of adult hemodialysis patients who use arteriovenous fistulas or have a maturing fistula as the primary mode of vascular access at the start of renal replacement therapy: Target 34.8%
 Table 3.13CKD-12 Increase the proportion of dialysis patients waitlisted and/or receiving a kidney transplant from a deceased donor within 1 year of end-stage renal disease (ESRD) start (among patients under 70 years of age): Target 18.7% of dialysis patients
 Table 3.14CKD-13.1 Increase the proportion of patients receiving a kidney transplant within 3 years of end-stage renal disease (ESRD): Target 20.1%
 Figure 3.2CKD-13.1 Geographic distribution of the adjusted proportion of patients receiving a kidney transplant within 3 years of end-stage renal disease (ESRD), by state, in the U.S. population, 2012: Target 20.1%
 Table 3.15CKD-13.2 Increase the proportion of patients who receive a preemptive transplant at the start of end-stage renal disease (ESRD): No applicable target
 Table 3.16CKD-14.1 Reduce the total number of deaths for persons on dialysis: Target 187.4 deaths per 1,000 patient years
 Table 3.17CKD-14.2 Reduce the number of deaths in dialysis patients within the first 3 months of initiation of renal replacement therapy: Target 335.0 deaths per 1,000 patient years at risk
 Table 3.18CKD-14.3 Reduce the number of cardiovascular deaths for persons on dialysis: Target 81.3 deaths per 1,000 patient years at risk
 Table 3.19CKD-14.4 Reduce the total number of deaths for persons with a functioning kidney transplant: Target 27.8 deaths per 1,000 patient years at risk
 Table 3.20CKD-14.5 Reduce the number of cardiovascular deaths in persons with a functioning kidney transplant: Target 4.5 deaths per 1,000 patient years at risk
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Healthy People 2020

  • In this chapter, we examine data for 11 Healthy People 2020 (HP2020) objectives—10 for CKD and one for diabetes—spanning 20 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.
  • In 2015, 12 of the 19 HP2020 indicators with specific targets met the established goals.
  • This year we introduce an examination of Objective CKD-5—Increase the proportion of persons with diabetes and chronic kidney disease who receive recommended medical treatment with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (Table 5). Progress is still needed to meet the established hypertension treatment target of 76.3%.
  • 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-five 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 10) and CKD 11-2 (Proportion of adult hemodialysis patients who use catheters as the only mode of vascular access; Table 11). In 2015, the overall proportion of prevalent patients using an arteriovenous fistula was 63.8%, essentially unchanged from 2013 and 2014.
  •  The all-cause mortality among prevalent dialysis patients in 2015 was 174.4 deaths per 1,000 patient years (HP2020 objective CKD-14.1, Table 16). Although this rate was a slight increase from 2014, it indicates a 16.2% decrease in the mortality rate since 2006. This increase, although slight, represents the first increase in dialysis mortality since 2001 (data not shown). In the pediatric population (aged <18 years), mortality rates have improved by over 40% in the past decade.

Introduction

For more than three decades, the Healthy People initiative has served as the nation’s agenda for health promotion and disease prevention. Coordinated by the United States (U.S.) Department of Health and Human Services, the initiative provides a vision and strategy for improving the health of all Americans by setting priorities, identifying baseline data and 10-year targets for specific objectives, monitoring outcomes, and evaluating progress. In each decade since its inaugural iteration in 1980, the Healthy People program has released updated plans that reflect emerging health priorities, and have helped to align health promotion resources, strategies, and research.

Healthy People 2020 (HP2020) was launched on December 2, 2010 (HP2020, 2010). It represents the fourth-generation plan, and encompasses more than 1,000 health objectives organized into 42 different topic areas. Built on the success of the three previous initiatives, HP2020 seeks to achieve the following overarching goals:

  • to assist all Americans in attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death,
  • to achieve health equity, eliminate disparities, and improve the health of all groups,
  • to create social and physical environments that promote good health for all, and
  • to promote quality of life, healthy development, and healthy behaviors across all life stages (HP2020, 2010).

One of the key priorities of the HP2020 initiative is to “reduce new cases of chronic kidney disease (CKD) and its complications, disability, death, and economic costs.” The development of CKD and its progression to end-stage renal disease (ESRD) is a major source of diminished quality of life in the U.S., and is responsible for significant premature mortality. The HP2020 CKD objectives were designed to reduce the long-term burden of kidney disease, increase lifespan, improve quality of life, and to eliminate related health care disparities. To accomplish these goals the HP2020 program developed 14 objectives related to CKD, encompassing 24 total indicators with targets designed to evaluate the program’s success. Herein, we provide data for 10 of these objectives, for which USRDS serves as the official data source, as well as information on urine albumin testing in non-CKD patients diagnosed with diabetes mellitus (DM).

It is important to highlight that one of the four overarching goals of HP2020 is to eliminate health care disparities. While much of the data showed promising trends relevant to this goal, overall progress did not always translate into reduced differences across groups. To facilitate comparisons we present data overall and by racial, ethnic, sex, and age subgroups. In many cases, while the overall population may have met an objective, one or more subgroups may have fallen well short. Conversely, for some objectives the overall findings may have been stable, yet with significant improvements observed in some subgroups.

Table A presents the current targets for each of the 11 objectives (with 20 total indicators). Many of these targets are based on percentage changes from an index value or year, e.g. a 10% reduction in the number of new cases of ESRD per million population from the 2007 value (CKD-8). We have updated these targets to reflect the changes in the index values that have resulted from recent data, change in the standard population year for adjusted analyses, and improved methodology. Additional information on the HP2020 program CKD objectives is available on the Healthy People 2020 website.

Table A HP2020 CKD Objectives

Methods

The findings presented in this chapter were drawn from multiple data sources, including the Centers for Medicare & Medicaid Services (CMS), the Organ Procurement and Transplantation Network (OPTN), the Centers for Disease Control and Prevention (CDC), and the United States Census. Details of these are described in the Data Sources section of the ESRD Analytical Methods chapter.

See the Analytical Methods Used in the ESRD Volume section of the ESRD Analytical Methods chapter for an explanation of the analytical methods used to generate the study cohorts, figures, and tables in this chapter. Downloadable Microsoft Excel and PowerPoint files containing the data and graphics for these figures and tables are available on the USRDS website.

Recommended Care

Acute kidney injury (AKI) has become established as an important risk factor for the subsequent development, or worsening, of CKD. This association is apparent even for less severe stages of AKI and continues after apparent recovery from AKI. Unfortunately, the published literature suggests that the rate of post-AKI renal follow-up is quite low. This objective aims to promote improved renal follow-up within six months after an episode of AKI. Post-AKI follow-up allows for early identification of CKD development and provides an opportunity to institute renoprotective measures early in the course of evolving disease.

Over the past decade, there has been a steady increase in the percentage of Medicare patients with AKI who received follow-up renal evaluation, reaching 17.4% in 2015 (see Table 1). This is the fifth consecutive year that the HP2020 goal of 12.3% has been achieved. While these trends are encouraging, the absolute rates of follow-up remained quite low.

Men were more likely to receive post-AKI follow-up renal evaluation as compared with women, and a slightly higher proportion of Blacks/African Americans had follow-up compared to Whites. The proportion of patients receiving post-AKI renal evaluation decreased with older age. Among patients aged 65-74, 22.1% received follow-up evaluation, compared to 18.2% of patients aged 75-84, and only 9.7% of those aged 85 and older.

Table 3.1 CKD-3 Increase the proportion of hospital patients who incurred acute kidney injury who have follow-up renal evaluation in 6 months post discharge: Target 12.3%

It is recommended that patients with DM have urine albumin measurement to detect early diabetic nephropathy. In the Medicare population, there has been steady improvement in the proportion of patients with diagnosed DM who received this test annually. The rate reached 47.6% in 2015, once again meeting the HP2020 target (see Table 2).

The increase in urine albumin measurements occurred across all age and race groups, and in both men and women. However, the proportion of patients with DM who had urine albumin measurements declined with age, falling from 51.9% in the 65-74 age group to 34.1% in patients older than 85 years. Proportions were somewhat similar when examined by race, with the exception of American Indians or Alaska Natives. While this group had a low rate of 30.1%, testing in this population may have been under-reported as services rendered through the Indian Health Service (IHS) are not included in the claims reported to the Medicare system.

Table 3.2 D-12 Increase the proportion of persons with diagnosed diabetes who obtain an annual urinary microalbumin measurement: Target 37.0%

HP2020 CKD Objective 4.1 examines the proportion of patients with CKD who receive recommended medical testing, including for serum creatinine, urine albumin, and lipids (Table 3). In the Medicare population aged 65 and older, 33.8% of CKD patients underwent serum creatinine, lipid, and urine albumin testing in 2015, surpassing the HP2020 goal of 28.4% for the sixth consecutive year. This represents a 10-percentage point increase (23.5%-33.8%) over the base year of 2006.

Similar to trends for other recommended measures, the proportion of patients receiving these tests declined with rising age; testing occurred in 41.3%, 35.7%, and 20.6% of individuals in the 65-74, 75-84, and 85 years and older age groups. As compared to females, a higher proportion of males had recommended testing. When examining race and ethnicity, Asians had the highest proportion of recommended testing, followed by Hispanic or Latino patients. American Indians or Alaska Natives had the lowest proportion, although once again this may relate to lack of data capture from the IHS.

Table 3.3 CKD-4.1 Increase the proportion of persons with chronic kidney disease who receive medical evaluation with serum creatinine, lipids, and microalbuminuria: Target 28.4%

Patients with both CKD and type 1 or type 2 DM require comprehensive laboratory monitoring to assess for the development of complications. The glycosylated hemoglobin (HgbA1c) test provides an assessment of blood glucose control over prolonged periods. Diabetic retinopathy, an early sign of poor glucose control, can be detected through regular eye examinations, and lipid levels can be used to estimate cardiovascular risk. In 2015, 30.1% of Medicare patients with CKD and DM received serum creatinine, urine albumin, HgbA1c, and lipid testing, as well as an eye examination (see Table 4). This continues the annual increases observed over the past decade, surpassing the HP2020 goal of 25.3% for the sixth consecutive year.

Once again, the proportion of patients tested declined with rising age; testing occurred in 32.4%, 31.7%, and 22.3% of individuals in the 65-74, 75-84, and 85 years and older age groups.

Table 3.4 CKD-4.2 Increase the proportion of persons with type 1 or type 2 diabetes and chronic kidney disease who receive medical evaluation with serum creatinine, microalbuminuria, A1c, lipids, and eye examinations: Target 25.3%

The use of angiotensin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARBs) is a recommended part of the medical management of patients with CKD and DM. In 2015, 71% of Medicare patients aged 65 and older received one of these agents. This was a slight decrease from 2014, and fell short of the HP2020 goal of 76.3%. The treatment rate of approximately 70% has remained essentially unchanged since 2007.

A slightly higher proportion of females received ACE inhibitor or ARB therapy as compared to males. Those of White race had the lowest proportion of use at 70.2%, compared to 72.3% of Blacks and 77.1% of Hispanic or Latino patients. Use of ACE inhibitors and ARBs decreased with increasing age group.

Table 3.5 CKD-5 Increase the proportion of persons with diabetes and chronic kidney disease who receive recommended medical treatment with angiotensin-convertingenzyme inhibitors or angiotensinII receptor blockers: Target 76.3%

Incidence of End-Stage Renal Disease

The rate of new cases of ESRD declined from 2006 through 2012, although the 2015 rate of 361.6 incident cases per million population (PMP) remained above the target of 352.0, established as a 10% decrease from the 2007 value of 391.1. As shown in Table 6, substantial variation in the incidence of ESRD across race and ethnicity continued as a persistent challenge. Consistent with previous years, in 2015 higher rates of incident ESRD were seen among Blacks, at 895.0 new cases PMP and Native Hawaiians and Pacific Islanders, with 2,516.7 PMP, as compared to Whites with 294.0 and Asians with 314.9. The most substantial decline in 2015 occurred among Blacks, where incidence decreased from 917.5 to 895.0 new cases PMP. Although the overall incidence rates remained largely unchanged from 2012 to 2015, they declined for every race group except Whites, who saw a slight increase. Thus, as compared to Whites, the ESRD rate ratio for American Indians and Alaska Natives fell from 1.6 to 1.3 during these years, while the rate ratio for Blacks decreased from 3.3 to 3.0.

It should be noted that the extraordinarily high incidence rates among Native Hawaiians and Pacific Islanders might in part result from differential race reporting between the Census Bureau and the ESRD Medical Evidence Report form (CMS 2728) data collections. Although in the Census one-half of Native Hawaiians and Pacific Islanders self-identified as of multiple races, only 7% did so in the CMS 2728. At 492.0 PMP, the rate of incident ESRD among Hispanics was 35.2% greater than for non-Hispanics, at 364.0 PMP. This represents an additional narrowing of the gap of 38.3% seen in 2014.

Rates between the sexes remained stable, with 457.7 new cases PMP among men, which is 61.9% higher than the rate of 282.7 cases PMP among women. This represents an overall gap increase as compared to 2006 levels, when males had a rate 53.3% higher than females.

Kidney Failure Resulting from Diabetes

In 2015, the overall rate of kidney failure due to DM was 164.1 PMP. This was the third consecutive year of increase, and rates remained above the target of 154.4 PMP (Table 7). Males continued to have a higher rate of diabetic kidney failure than did females, at 201.8 compared with 132.1 PMP.

The degree of kidney failure due to DM varied widely by race, and was markedly higher in Blacks as compared to Whites, at 393.5 versus 139.8 PMP. However, rates in Blacks have decreased by 21.7% since 2006 while remaining roughly constant among Whites. American Indians and Alaska Natives are also at high risk for kidney failure due to DM. As recently highlighted by the Centers for Disease Control and Prevention (CDC, 2017), however, Native Americans have also experienced the greatest improvement in this area, with a 25.0% decline since 2006. The extraordinarily high rates among Native Hawaiians and Pacific Islanders again may have been influenced by differential race reporting between the Census Bureau and the CMS 2728 data collections.

Table 3.6 CKD-8 Reduce the rate of new cases of end-stage renal disease (ESRD): Target 352.0 new cases per million population

Table 3.7 CKD-9.1 Reduce kidney failure (or end-stage renal disease, ESRD) due to diabetes: Target 154.4 per million population

In 2015 the adjusted rate of kidney failure among persons with DM was 2378 PMP (adjustment by age, sex, and race; see Table 8), failing to achieve the HP2020 target of 2354.4 PMP. This was the third consecutive year in which an increase in rate was observed, and the first year since 2009 when the rate was above the HP2020 target.

Rates in 2015 varied among races, and remained highest in Blacks with DM at 3497 PMP, compared to 2148 PMP in their White counterparts. Of note, rates in Whites have increased annually since 2011. In contrast, rates of kidney failure in Blacks with DM have fallen each year since 2007, an overall 21.9% decrease during that period.

Nephrologist Care

At 36.0%, the proportion of CKD patients in 2015 receiving care from a nephrologist at least 12 months before the start of renal replacement therapy exceeded the HP2020 goal of 30.0%, which was based on a 10% increase over the 2007 proportion (Table 9). Percentages by ethnicity were lowest among Hispanics and Latinos, at 28.1%. Variations by race continued to be observed, with Whites (37.0%) and Asians (37.6%) having a greater proportion of care than Blacks (32.0%) and Native Hawaiians and Pacific Islanders (31.5%). As overall percentages have increased, the gap between the race groups receiving the least and most nephrologist care has increased from a 5.2% difference (22.7-27.9%) in 2006 to 6.1% (31.5-37.6%) in 2015.

Greater variation was observed by age, with the proportions ranging from 29.3% among those aged 18-44 to 48.3% among those under age 18. In contrast to the differences seen by race and age, percentages of pre-ESRD nephrologist care were similar by sex, at 35.4% among males and 35.9% among females.

Table 3.8 CKD-9.2 Reduce kidney failure (or end-stage renal disease, ESRD)due to diabetes among persons with diabetes: Target 2,354.4 per million population

Table 3.9 CKD-10 Increase the proportion of chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy: Target 30.0%

Substantial geographic variation was also observed in the proportion of CKD patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy (Figure 1). While in 2015, 45 of the U.S. states met or exceeded the HP2020 target of 30.0%, percentages varied by nearly 50% from the twentieth percentile (34.2%) to the eightieth percentile (50.1%). In general, the highest percentages of patients receiving this care were observed in the North Atlantic and Northern Plains regions, with the lowest occurring in the Mid-South and Southern Plains states.

Figure 3.1 CKD-10 Geographic distribution of the adjusted proportion of chronic kidney disease patients receiving care from a nephrologist at least 12 months before the start of renal replacement therapy, by state, in the U.S. population, 2015: Target 30.0%

Vascular Access

In the 2014 ADR, we introduced data from CROWNWeb, a dialysis data reporting system launched by CMS in 2012. Prior to the 2014 ADR, we derived data regarding vascular access from the ESRD Clinical Performance Measures (CPM) Project that only collected this information through 2007.

Vascular access is an important aspect of hemodialysis care, and arteriovenous (AV) fistulas are clinically established as the primary access of choice. The HP2020 CKD Objective 11.1 examines the use of AV fistulas among prevalent hemodialysis patients (see Table 10).

In 2015, 63.8% of prevalent adult hemodialysis patients were using an AV fistula as their primary access. This rate decreased slightly from 2014, yet was more than double the proportion reported in ESRD CPM data for 2000 (29.9%) and well above the last available ESRD CPM data from 2007 (49.6%; USRDS, 2012). This overall prevalence exceeded the previous HP2020 target of 50.6%, although comparisons should be made with caution as this target was derived from a different data source (ESRD CPM).

Among race groups, Blacks had the lowest percentage of AV fistula use at 59.2%, compared to 65.9% of Whites, 68.6% of Asians, 76.4% of American Indians or Alaska Natives, and 69.3% of Native Hawaiians or other Pacific Islanders. The proportion of males with an AV fistula was higher than females, at 69.6% compared to 56.3%.

Table 3.10 CKD-11.1: Increase the proportion of adult hemodialysis patients who use arteriovenous fistulas as the primary mode of vascular access: Previous data source target 50.6%

In comparison to AV fistulas, reliance on hemodialysis catheters as primary vascular access is associated with increased morbidity and mortality. HP2020 CKD Objective 11.2 aims to reduce the proportion of hemodialysis patients that are dependent on catheters. Data for this objective were also obtained from CROWNWeb and thus interpretation of target achievement may be limited, as the former HP2020 target was derived from a different data source (ESRD CPM Project).

In 2015, 16.3% of prevalent adult hemodialysis patients were using catheters as the primary mode of access (Table 11), at about the same rate as in 2014. This represents an improvement from the most recent available data from the ESRD CPM project, which found that 27.7% of prevalent hemodialysis patients were using a catheter as their primary access in 2007.

Percentage of catheter use was highest among Whites at 17.4% compared to 15.3% in Blacks, 13.3% in Asians, 11.5% in American Indian or Alaska Natives, and 14.2% in Native Hawaiians or Pacific Islanders. The proportion of patients with catheter access increased by age group after the age of 45, rising from 14.5% among those aged 45-54 years to 27.2% in those aged 85 years and older.

Table 3.11 CKD-11.2: Reduce the proportion of adult hemodialysis patients who use catheters as the only mode of vascular access: Previous data source target 26.1%

Programs such as HP2020 and the Fistula First Initiative (a U.S. national quality improvement program initiated in 2003) continue to work to increase the use of fistulas, and to promote early placement prior to initiation of ESRD therapy. In 2015, 35.5% of incident hemodialysis patients had a maturing arteriovenous fistula, or were using one as their primary vascular access (see Table 12). This was a slight rate decrease from a high of 37.3% in 2013, yet it represents an overall relative increase of 11.6% since 2006, and marks the fifth consecutive year meeting the target for this objective.

By race, in 2015 Blacks had the lowest proportion of AV fistula at 33.3%, compared to 36.0% in Whites, 43.2% in American Indian or Alaska Natives, 38.6% in Asians, and 37.5% in Native Hawaiians or Pacific Islanders. By age group, patients aged 65-74 had the highest proportion at 37.3%, compared to just 22.8% in patients aged 18-24.

Transplantation

The proportion of ESRD patients younger than age 70 who were wait-listed or received a kidney transplant from a deceased donor within one year of initiating dialysis therapy decreased between 2013 (17.3%) and 2015 (15.7%; Table 13). Across race categories, the HP2020 target of 18.7% was only exceeded by those of Asian race (28.7%). Males (16.3%) were closer to the target than females (14.7%). Groups furthest from the target included American Indians or Alaska Natives (9.9%), those aged 65-69 (10.5%), Blacks (12.8%) and Native Hawaiians and Pacific Islanders (12.9%). Gaps between groups with the highest and lowest percentages have remained stable, showing only minor decreases over time.

At 13.2%, the proportion of 2012 patients younger than age 70 who received a kidney transplant within three years of starting ESRD therapy remained well below the HP2020 target of 20.1%, which was based on a 10% improvement over the value in 2004 (see Table 14). This continued the slow but consistent decrease observed since 2004, when 18.3% of patients received a transplant within three years of initiating ESRD therapy.

Rates were lowest among Blacks (7.0%), and American Indians and Alaska Natives (7.2%), and were highest among Whites (16.2%) and Asians (16.2%). At 13.5%, males were slightly more likely to receive a transplant than females, at 12.7%. The percentage of patients receiving transplants decreased with age, from 74.4% in pediatric patients to 7.0% among those aged 65-69.

Table 3.12 CKD-11.3 Increase the proportion of adult hemodialysis patients who use arteriovenous fistulas or have a maturing fistula as the primary mode of vascular access at the start of renal replacement therapy: Target 34.8%

Table 3.13 CKD-12 Increase the proportion of dialysis patients waitlisted and/or receiving a kidney transplant from a deceased donor within 1 year of end-stage renal disease (ESRD) start (among patients under 70 years of age): Target 18.7% of dialysis patients

Table 3.14 CKD-13.1 Increase the proportion of patients receiving a kidney transplant within 3 years of end-stage renal disease (ESRD): Target 20.1%

Geographic variation in the proportion of patients receiving a kidney transplant within three years of ESRD was also observed (Figure 2). In 2012, nine of the U.S. states met or exceeded the HP2020 target of 20.1%; these were almost exclusively located in the North Atlantic and Northern Plains regions. States with the lowest percentages were generally observed throughout the South and in the West.

In 2015, the percentage of patients receiving a preemptive transplant at the start of ESRD remained stable at 3.6%, consistent with the previous four years (see Table 15). Not surprisingly, preemptive transplants were most common in pediatric patients, reaching 38% among those aged 5 to 11. Proportions were equivalent between females at 3.6% and males at 3.7%. Broad variation was observed by race, however, ranging from 0.9% among Blacks and 1.4% for American Indian and Alaska Natives to 3.8% among Whites and 3.9% for Asians.

Figure 3.2 CKD-13.1 Geographic distribution of the adjusted proportion of patients receiving a kidney transplant within 3 years of end-stage renal disease (ESRD), by state, in the U.S. population, 2012: Target 20.1%

Table 3.15 CKD-13.2 Increase the proportion of patients who receive a preemptive transplant at the start of end-stage renal disease (ESRD): No applicable target

Mortality

As demonstrated in Table 16, the total death rate among prevalent patients on dialysis has fallen by more than 19%, from 216.7 deaths per 1,000 patient years in 2006 to 174.4 in 2015, remaining below the HP2020 target of 187.4 for the fifth consecutive year. In 2015, mortality was slightly lower among males at 172.6 deaths per 1,000 patient years, compared to females, at 176.9 deaths. The lowest morality rate occurred in 2014 at 172.0 per 1,000 patient years.

Since 2006, reductions in mortality rates have been observed across all age groups, with the largest reduction—approximately 42.4% fewer deaths—for patients younger than 18 years. This rate decreased from 43.9 deaths per 1,000 patient years in 2006, to 25.3 deaths 2015. Patients aged 0-4 experienced more than a 50% reduction in mortality rates, although this decrease represents a relatively small numbers of deaths, due to the relatively low death rates and proportion of patients in this group. Overall rates were highest among patients aged 65 and older, at 260.4 deaths per 1,000 patient years.

Mortality rates among Whites were highest, and continued to exceed the target at 207.4 deaths per 1,000 patient years. Rates were lowest among Native Hawaiians and Pacific Islanders (115.5 deaths per 1,000 patient years), Asians (126.4 deaths per 1,000), and Hispanics (128.5 per 1,000).

Since 2006, the rate of mortality among dialysis patients in the first three months after initiation has fallen by 18.3%, from 381.2 deaths per 1,000 patient years to 311.5 in 2015. For the fourth year in a row, the rate was below the HP2020 target of 335.0 deaths per 1,000 patient years (see Table 17). Whites remained the only racial group who exceeded the target rate at 366.2 deaths per 1,000 patient years. Rates were lowest among American Indians and Alaska Natives, with 134.9 deaths. Native Hawaiians and Pacific Islanders showed a rate of 139.4 deaths per 1,000 patient years at risk, and those with Hispanic or Latino ethnicity, with 192.6 deaths. Males had slightly lower mortality rates than females, at 309.1 deaths per 1,000 patient years compared to 314.9. Mortality rates were highest among those aged 85 years or older, at 865.0 deaths per 1,000 patient years.

Table 3.16 CKD-14.1 Reduce the total number of deaths for persons on dialysis: Target 187.4 deaths per 1,000 patient years

Table 3.17 CKD-14.2 Reduce the number of deaths in dialysis patients within the first 3 months of initiation of renal replacement therapy: Target 335.0 deaths per 1,000 patient years at risk

Since 2006, the overall rate of cardiovascular death among those on dialysis has fallen by approximately 30%. In 2015, with a rate of 67.0, the HP2020 goal of 81.3 cardiovascular deaths per 1,000 patient years at risk was met for the sixth year in a row (see Table 18). Though both exceeded the target, 2015 rates were lower among females (65.7 deaths per 1,000) as compared with males (68.0 deaths). Rates were lowest among Blacks with 54.4 deaths per 1,000 and Asians, with 57.3 deaths. Cardiovascular death continued to be highest among Whites, at 76.9 deaths per 1,000 patient years. Since 2006, large reductions in rates by age have been observed. The largest reduction—approximately 33% fewer deaths—was seen for patients older than 65 years in 2015, with 94.1 deaths per 1,000 patient years, compared to the 2006 rate of 140.6 deaths.

The total death rate for patients with a functioning transplant has not improved since 2006, and in 2015, at 32.7 deaths per 1,000 patient years at risk, still remained above the HP2020 target of 27.8 (Table 19). Consistent with previous trends, in 2015 males experienced higher rates of 34.9 deaths per 1,000 patient years, as compared with females at 29.5 deaths per 1,000. Rates were lowest among Asians (23.5 per 1,000) and highest among Whites (34.3 per 1,000), and American Indians and Alaska Natives (32.0 per 1,000). Death rates for patients with a functioning transplant were highest among those aged 65 and older, at 73.4 deaths per 1,000 patient years compared with those aged 45-64, at 24.8, and those aged 18-44, at 6.9 deaths.

Table 3.18 CKD-14.3 Reduce the number of cardiovascular deaths for persons on dialysis: Target 81.3 deaths per 1,000 patient years at risk

Table 3.19 CKD-14.4 Reduce the total number of deaths for persons with a functioning kidney transplant: Target 27.8 deaths per 1,000 patient years at risk

In 2015, for the eighth consecutive year, the HP2020 target of 4.5 cardiovascular deaths per 1,000 patient-years was met among transplant recipients. The rate of cardiovascular mortality among transplant recipients has fallen by 47.1% since 2006, to the observed 2.7 deaths per 1,000 patient-years in 2015 (see Table 20). Rates were lowest among Hispanics or Latinos at 1.9 per 1,000 patient-years. Blacks and Whites had higher rates, at 2.7 and 2.8 deaths per 1,000 patient-years. Also consistent with prior trends, rates were lower among females at 2.5 deaths per 1,000 patient-years, compared with males at 2.9 per 1,000 patient-years, although both remained below the HP2020 target.

Table 3.20 CKD-14.5 Reduce the number of cardiovascular deaths in persons with a functioning kidney transplant: Target 4.5 deaths per 1,000 patient years at risk

References

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