Haifeng Guo

Excerpts From the US Renal Data System 2009 Annual Data Report

This 21st US Renal Data System Annual Data Report covers data through 2007, and again includes a section on chronic kidney disease (CKD) in the United States. Using NHANES and employer group health plan data, we estimate the relationship between kidney disease markers and mortality risk and the likelihood of blood pressure and lipid control by CKD stage; illustrate use of the new ICD-9-CM CKD diagnosis codes; and report on morbidity, mortality, care and costs during the transition to ESRD. New chapters address CKD patient care, the transition to ESRD, and acute kidney injury. In 2007, 111,000 patients started end-stage renal disease (ESRD) therapy, and the prevalent population reached 527,283 (including 368,544 dialysis patients); 17,513 transplants were performed, and 158,739 patients had a functioning graft at year’s end. Program expenditures reached

United States Renal Data System 2008 Annual Data Report Abstract

35.3 billion, with

Septicemia in the United States Dialysis Population, 1991 to 1999

23.9 billion from Medicare (accounting for 5.8% of total Medicare expenditures). The incident rate fell 2.1%, to 354 per million. Fistula use in prevalent patients declined 2.6 percent; catheter use continues to be a concern. The percentage of patients with hemoglobin levels above 13 g/dl has fallen since 2006, but levels in the incident population frequently exceed 12. First-year mortality and morbidity among hemodialysis patients—particularly the increasing rate of hospitalizations due to infections—continue to be major concerns, and pediatric patient survival has not improved. The public health impact of kidney disease is larger than previously appreciated, and early detection, education, intervention, and risk factor control need to address the heavy burden of cardiovascular disease and adverse events in this vulnerable population.

Atherosclerotic Renovascular Disease in Older US Patients Starting Dialysis, 1996 to 2001

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Atherosclerotic renovascular disease in the United States

The clinical epidemiology of septicemia in dialysis populations remains poorly defined. In this historical cohort study of 393,451 U.S. dialysis patients, International Classification of Disease, Ninth Revision, Clinical Modification discharge diagnosis codes were used to compare first-year septicemia admission rates in annual incident cohorts from 1991 to 1999 and to calculate subsequent cardiovascular event and mortality rates. Hemodialysis (compared with peritoneal dialysis) as initial therapy and starting dialysis in more recent years were the principal antecedents of septicemia. In hemodialysis patients, adjusted first admission rates (expressed throughout as first episodes per 100 patient-years) rose by 51%, from 11.6 in 1991 to 17.5 in 1999. In peritoneal dialysis patients, rates rose from 5.7 in 1991, peaked at 9.2 in 1997, and declined to 8.0 in 1999. Mortality rates after septicemia were similar to mortality rates after major cardiovascular events. Septicemia was associated with developing myocardial infarction, congestive heart failure, stroke, and peripheral vascular disease with adjusted risk ratios of 4.1, 5.5, 4.1, and 3.8 in the initial 6 mo after admission for septicemia and 1.7, 2.0, 2.0, and 1.6 after 5 yr, respectively. Septicemia, which is associated with increased cardiovascular and death risk, has become more common in dialysis patients in the United States.

General Medical Care among Patients with Chronic Kidney Disease: Opportunities for Improving Outcomes

Background— Temporal trends regarding the epidemiology of atherosclerotic renovascular disease (ARVD) in dialysis populations are poorly defined. Methods and Results— United States Renal Data System data were used to identify patients aged 67 years or older at dialysis inception between 1996 and 2001 (n=146 973). Medicare claims in the preceding 2 years were used to identify ARVD and revascularization procedures. Prior ARVD rose from 7.1% to 11.2% between 1996 and 2001 (adjusted odds ratio [AOR], 1.68). Other associations included hypertensive end-stage renal disease (ESRD; AOR, 2.21), ESRD network (AOR, 0.44 in network 17 versus 1.00 in network 1), peripheral vascular disease (AOR, 1.65), black race (AOR, 0.44), urologic cause of ESRD (AOR, 0.57), age >85 years (AOR, 0.58), substance dependency (AOR, 0.62), and inability to ambulate or transfer (AOR, 0.67). The proportion of ARVD patients undergoing revascularization rose from 14.6% to 16.7% between 1996 and 2001 (AOR, 1.27). Other associations included hypertension (AOR, 2.10), ESRD network (AOR, 2.07 for network 13 versus 1.00 in network 1), age >85 years (AOR, 0.53), and black race (AOR, 0.54). The rise in ARVD was not reflected in the proportion of patients with renovascular disease listed as cause of ESRD on the Medical Evidence Report at dialysis inception (5.5% in 1996, 5.0% in 2001). Conclusions— ARVD diagnoses have become more common in older patients beginning dialysis therapy. The association of demographic factors including age, race, and geographic residence with utilization patterns suggests possible barriers to care.

Temporal trends in red blood transfusion among US dialysis patients, 1992-2005.

Atherosclerotic renovascular disease (ARVD) is an increasingly recognized clinical condition that is diagnosed predominantly in older patients. Here we used annual United States Medicare 5% Denominator Files and studied 16,036,904 patients, 66 years of age and older, to quantify trends in diagnostic rates, associations, treatment, and outcomes of ARVD over a 13-year period. Overall, there was an ARVD rate of 3.09 per 1000 patient-years, which rose progressively with an adjusted hazard ratio of 3.35, comparing data from 1992 to 2004. Within 6 months of disease diagnosis, 13.4% of patients had undergone revascularization. A biphasic pattern of revascularization was found where the adjusted hazard ratios significantly increased in a progressive manner until 1999, following which there was a decline through 2004, which was not significant. The method of revascularization changed markedly over time with endovascular intervention steadily replacing direct surgical revascularization. As a time-dependent variable, ARVD was associated with excess mortality in each calendar year, albeit with declining hazard ratio estimates in more recent years. Among patients with this disease, revascularization was associated with mortality adjusted hazard ratios <1 in each year. Our study shows the diagnosis of ARVD has substantially risen in the United States but the survival implications were not fully explained by other comorbid vascular diseases.

Prehemodialysis care by dietitians and first-year mortality after initiation of hemodialysis.

Suboptimal health care during advancing chronic kidney disease (CKD) may result in greater morbidity and cost once dialysis is started and may preclude future transplantation. Medicare data were examined for the prevalence of selected general health, diabetes, and CKD interventions in a national cohort of patients in the 2 yr before dialysis initiation and compared with a contemporaneous non-CKD cohort. A total of 24,778 individuals who were aged > or =67 yr composed the CKD cohort, and 1,046,136 individuals who were aged > or =67 yr did not have CKD. Among patients with diabetes and CKD, fewer than two thirds had claims for eye examinations, 75% for HbA(1C) testing, and 68% for lipid testing, with similar proportions in the non-CKD cohort. Among those without diabetes, 47 and 54% of the CKD and non-CKD cohorts, respectively, had claims for lipid testing. Fewer than 50 and 15% had claims for influenza and pneumococcal vaccination, respectively, with slightly lower proportions among patients with CKD. Claims for cancer tests were found for 14 to 41% and 29 to 52% of individuals with and without CKD, respectively, depending on the type of cancer. A greater proportion of patients with diabetes tended to have claims for tests in both cohorts. In the CKD cohort, claims for anemia testing and parathyroid hormone levels were available in fewer than 50 and 15%, respectively, and claims for permanent vascular access were found for only 30% of hemodialysis patients. This study provides further evidence that patients with CKD may not be receiving general health and CKD care according to current recommendations.

The association of pneumococcal vaccination with hospitalization and mortality in hemodialysis patients

BACKGROUND Studies addressing patterns and trends in red blood cell transfusion use in US hemodialysis patients surprisingly have received little attention in the last decade. STUDY DESIGN Retrospective cohort study. SETTING & PARTICIPANTS Point prevalent (as of January 1 of each calendar year 1992 to 2005) dialysis patients with Medicare Part A and Part B as primary insurance (n = 77,347 in 1992, n = 164,933 in 2005). The 6 months preceding January 1 of each year were used to assemble a comorbidity profile based on administrative claims data. PREDICTORS Hemoglobin levels, patient characteristics, comorbid conditions. OUTCOMES Blood transfusion events obtained from Part A and Part B files using code files for both whole and packed red blood cell transfusions and hemoglobin levels. MEASUREMENTS Comorbid conditions were defined by the presence of 1 or more inpatient/outpatient institutional claims (inpatient hospitalization, skilled nursing facility, or home health agency), 2 or more outpatient or physician/supplier claims, or 1 or more outpatient and 1 or more physician/supplier claims for atherosclerotic heart disease, congestive heart failure, cerebrovascular accidents/transient ischemic attacks, peripheral vascular disease, other cardiovascular diseases, chronic obstructive pulmonary disease, gastrointestinal disorders, liver disease, arrhythmia, and diabetes mellitus. RESULTS Raw transfusion rates decreased in both outpatient and inpatient settings from 535.33/1,000 patient-years for 1992 prevalent dialysis patients to 263.65/1,000 patient-years in 2005 (P for trend < 0.001, 1992 versus 1999 and 1999 versus 2005). Adjusted rates decreased similarly. This phenomenon could not be explained by changes in case mix. LIMITATIONS Cause, effect, and confounding cannot be separated in this observational study. The accuracy of blood transfusion billing data is unknown. Temporal trends may be related to factors other than erythropoiesis-stimulating agent use. CONCLUSION Transfusion events in hemodialysis patients decreased more than 2-fold from 1992 to 2005; most of the decrease occurred in the first 5 years after erythropoietin was introduced.

Meeting KDOQI Guideline Goals at Hemodialysis Initiation and Survival during the First Year

BACKGROUND Since January 2002, Medicare has provided payment for medical nutrition therapy for patients with chronic kidney disease. Few patients receive dietary counseling before end-stage renal disease onset; whether such counseling is associated with improved outcomes is unknown. STUDY DESIGN Retrospective cohort analysis. SETTING & PARTICIPANTS Patients who initiated hemodialysis therapy on June 1, 2005, to May 31, 2007, in the United States for whom predialysis dietitian care was reported on the Centers for Medicare & Medicaid Services Medical Evidence Report. PREDICTOR Dietitian care before end-stage renal disease onset. OUTCOME Time to death. MEASUREMENTS Propensity score for dietitian care calculated using logistic regression; Cox regression analysis used to compare time to death by predialysis dietitian care overall and stratified by tertiles of propensity score, adjusting for baseline characteristics. RESULTS Most patients (88%) received no dietitian care; 9% received dietitian care for 12 months or less, and 3% received dietitian care for more than 12 months before dialysis therapy initiation (total N = 156,440). Predialysis dietitian care was associated independently with higher albumin and lower total cholesterol levels at dialysis therapy initiation. There was evidence of an independent association between predialysis dietitian care for longer than 12 months and decreased mortality during the first year on dialysis therapy for the second tertile of propensity score. Adjusted mortality HRs were 1.16 (95% CI, 0.44-3.09; P = 0.8), 0.81 (95% CI, 0.71-0.93; P = 0.002), and 0.93 (95% CI, 0.86-1.01; P = 0.1) in the first, second, and third tertiles of propensity score, respectively. LIMITATIONS Information for dietitian care was missing for 18.6% of Medical Evidence Reports and has low sensitivity; including only incident dialysis patients precluded evaluation of an association between dietitian care and chronic kidney disease progression; the observational design allowed the possibility of residual confounding. CONCLUSIONS Our study suggests an independent association between predialysis dietitian care for more than 12 months and lower mortality during the first year on dialysis therapy.