The Incidence of End-Stage Renal Disease Is Increasing Faster than the Prevalence of Chronic Renal Insufficiency

The Incidence of End-Stage Renal Disease Is Increasing Faster than the Prevalence of Chronic Renal Insufficiency

Chi-yuan Hsu, MD, MSc;
Eric Vittinghoff, PhD;
Feng Lin, MS; and
Michael G. Shlipak, MD, MPH

From the University of California, San Francisco, San Francisco, California.

Abstract

Background: The steady increase in end-stage renal disease (ESRD) incidence is a worldwide public health crisis.

Objective: To determine whether the increasing incidence of ESRD in the United States is preceded by increased prevalence of chronic renal insufficiency.

Design: Birth cohort analysis.

Setting: Nationally representative Second and Third National Health and Nutrition Examination Surveys (NHANES II [1976–1980] and III [1988–1994]) and nationally comprehensive U.S. Renal Data System registry.

Patients: Adults, 20 to 74 years of age, surveyed in NHANES II (midpoint, 1978) and NHANES III (midpoint, 1991), and adults, 25 to 79 years of age, who developed ESRD in 1983 and 1996.

Measurements: Prevalent chronic renal insufficiency (estimated glomerular filtration rate, 15 to 59 mL/min per 1.73 m²) and new ESRD cases.

Results: From 1978 to 1991, the number of adults age 20 to 74 years with chronic renal insufficiency increased from 2.6 to 3.9 million, an increase in prevalence from 1970 to 2460 per 100 000 persons. However, the increased incidence of ESRD was even greater during this period. For every 1000 adults with chronic renal insufficiency in 1978, 9 new cases of ESRD developed in 1983, but every 1000 adults with chronic renal insufficiency in 1991 produced 16 new cases of ESRD in 1996 (relative risk, 1.7 [95% CI, 1.1 to 2.7]).

Limitations: We could not follow individual patients with chronic renal insufficiency for the development of ESRD, and we used estimated rather than measured glomerular filtration rate.

Conclusions: During the period examined, growth in incident ESRD outpaced growth in prevalent chronic renal insufficiency, demonstrating that the ESRD epidemic in the United States is not merely a function of more cases of kidney disease. Future research should examine other potential contributors to ESRD growth, such as improved survival from nonrenal diseases and more liberal entry into treatment programs.

Article and Author Information

Acknowledgments: The authors thank Dr. Ann O'Hare, Dr. Charles McCulloch, and Ms. Michelle Odden for their assistance.
Disclaimer: Some of the data reported here were supplied by the U.S. Renal Data System. The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy or interpretation of the United States government.
Grant Support: By the National Institutes of Health (grants DK61520 [Dr. Hsu] and HL68099 [Dr. Shlipak]). Dr. Shlipak was also supported by the Health Services Research and Development Service of the Veterans Affairs Administration (Advanced Research Career Development Award), American Federation for Aging Research (Paul Beeson Scholars Program), and Robert Wood Johnson Foundation (Generalist Scholars Program).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Chi-yuan Hsu, MD, MSc, Division of Nephrology, University of California, San Francisco, 513 Parnassus Avenue, 672 HSE, Box 0532, San Francisco, CA 94143-0532; e-mail, hsuchi{at}medicine.ucsf.edu.
Current Author Addresses: Dr. Hsu: Division of Nephrology, University of California, San Francisco, 513 Parnassus Avenue, 672 HSE, Box 0532, San Francisco, CA 94143-0532.
Dr. Vittinghoff: University of California, San Francisco, 1635 Divisadero Street, Suite 600, San Francisco, CA 94115.
Ms. Lin: University of California, San Francisco, 74 New Montgomery Street, Suite 600, San Francisco, CA 94105.
Dr. Shlipak: Veterans Affairs Medical Center, 4150 Clement Street (111A1), San Francisco, CA 94121.
Author Contributions: Conception and design: C.Y. Hsu, M.G. Shlipak.
Analysis and interpretation of the data: C.Y. Hsu, E. Vittinghoff, F. Lin, M.G. Shlipak.
Drafting of the article: C.Y. Hsu, M.G. Shlipak.
Critical revision of the article for important intellectual content: C.Y. Hsu, E. Vittinghoff, F. Lin, M.G. Shlipak.
Final approval of the article: C.Y. Hsu, E. Vittinghoff, F. Lin, M.G. Shlipak.
Statistical expertise: C.Y. Hsu, E. Vittinghoff, F. Lin.
Obtaining of funding: C.Y. Hsu, M.G. Shlipak.