Though we live in a world that dreams of ending

that always seems about to give insomething that will not

acknowledge conclusioninsists that we forever begin.

Brendan Kennelly “Begin”

Gbased on the number of patients per million peo-ple in the general population, and are adjusted for age, gender, and race. This classic approach is used because it is often difficult to define the true at-risk population for a specific disease. This year, however, we use the CDC’s county-level es-timates of diabetes in the U.S. (reported by the National Center for Health Statistics) to look at the incidence of ESRD caused by diabetes, comparing these rates in the true at-risk diabe-tes population to those calculated by the classic method to determine if we are making progress in slowing the rise of diabetic ESRD.

In rates based on this at-risk population, the incidence of ESRD due to diabetes has been fall-ing since the mid-1990s. This is in contrast to data reported by the USRDS, which use the general population as the at-risk group, and show that di-abetic ESRD rates peaked in 2003–2004 and have since remained relatively flat. Progress appearing when the diabetic population is used as the at-risk group should thus be viewed with some caution. Growth in the number of newly diagnosed dia-betic patients in the U.S. has quickened since the mid-1990s. These patients may take much longer to develop ESRD than those previously diag-nosed, creating a lead-time bias which dilutes the denominator and lowers the rates of ESRD.

In the last five years the USRDS has noted a continued growth in the number of treated pa-tients, but a slowing of the incident rates. More than 106,000 new patients began therapy for ESRD in 2005 (2.0 percent more than in 2004),

while the prevalent dialysis population reached 341,000 (3.3 percent more), and the prevalent transplant population grew to more than 143,693 (5.6 percent more). Both prevalent populations have more than tripled since 1988, while the number of incident patients has grown 159 per-cent. Since 1999, however, incident rates have been relatively stable, ranging from 333.1 per million population that year to 347.1 in 2005.

The median age of the incident population has reached 64.6. With continued growth in the baby boomer population, the disease rate for this group has begun to flatten. Rates of new ESRD due to diabetes remained fairly stable in 2005, at 152, and adjusted rates for ESRD due to glomeru-lonephritis have in fact been falling, from a peak of 33.1 in 1994 to 26.5 in 2005.

Even after adjustments for age, gender, race, and primary cause of ESRD, rates of ESRD vary widely across the U.S. This year we present new data on ESRD in the major metropolitan statisti-cal areas (MSAs) of the country. Among African Americans, for instance, the incidence of ESRD is greatest in the Pittsburgh, Pennsylvania MSA, while for whites (includes Hispanic whites) it is highest in the Los Angeles, California MSA. These variations may reflect different burdens of chronic kidney disease, as well as regional differences in the use of detection efforts and treatment inter-ventions in populations at risk for kidney failure.

Prevalent counts continue to rise, particularly for patients age 45–64, and the rate of prevalent ESRD rose 1.9 percent in 2005 to reach 1,569 per

Growth of the end-stage renal disease (ESRD) program is typically characterized by assessment of total patient counts at a single point in time (point prevalence), of new cases accepted for treatment (incidence), and of patients receiving kidney transplants. Disease rates are computed

822

million popula-tion. In absolute numbers,

the fastest growth is occurring among patients age 45–64; rates, however,

are rising most quickly among those age 65 and older. Regional variations in ESRD prevalence reflect

differences in adjusted survival, in part related to higher rates of transplantation in certain areas of the U.S.

This year we revisit earlier projections of the ESRD population, and update them to 2020. These projections show important similarities to the actual data. Growth of the prevalent population, for instance, is close to that projected in the 2000 ADR. Incident counts were over-estimated by 20 percent, but were within 1 percent of conservative projections published in JASN in 2001 (Xue et al.). Using SAS au-toregression models, we now project that the inci-dent population will grow to 143,000 by 2020; with the full Markov model, which addresses changing demo-graphics and the prevalence of diabetes in the U.S. popu-lation, we project 150,000. We also estimate a prevalent population nearing 800,000, and a dialysis population of 534,000. While actual growth will depend on care given to those with CKD, results using our current projection model show consistency between historical trends and the time-dependent Markov model.

We also proj-ect that total Medicare costs related to ESRD will approach $54 billion by 2020. In the 2000 ADR we es-timated an ESRD budget of $28 billion by 2010, and actual numbers have been ahead of these pro-jections. These projections are subject to changes in the payment system and in the development of prevention and treatment programs for CKD and ESRD. We will revisit them in the future, comparing them to actual data to determine the impact of changes in clinical

practice and preventive care. As in prior years, we re-

port here on patients with relatively rare causes of ESRD. Rates for ESRD due to AIDS, for example, have been fairly constant in the last decade. ESRD due to post-transplant (non-renal) complications has been ris-ing, a finding of particular concern.

Still to be determined is whether these data reflect short- or long-term trends, as the emergence of the baby boomers into a senior population may continue to contribute to the growth of the overall ESRD popula-tion, even with moderations in disease rates. The growth of diabetes in both the gen-

eral Medicare population and among younger patients is a concern as well. ½figure 2.1 counts projected using a Markov model, using data through 2005.

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highlightscontentsincidence 84 counts & rates by patient demographics & primary diag-nosis incident rates of ESRD based on at-risk populations 86 diabetes in the U.S. diabetic ESRD rates of ESRD in high-density areas 88 incident rates of ESRD in larger Metropolitan Statistical Areas prevalence 90 counts & rates by patient demographics & primary diagnosis projected ESRD counts & costs 92 incident & prevalent counts dialysis & transplant patients rare diseases 94 incident & prevalent rates ESRD network popula-tions 96 primary diagnosis mean age demographics of dialysis & transplant patients

figure 2.2 In 2005 the overall adjusted incidence of ESRD again re-mained stable, with the rate of 347 per million population only 1 percent higher than in 2001. figure 2.22 The adjusted prevalence of ESRD reached 1,569 per million population in 2005, 1.4 times higher than in 1995. Annual growth in the rate, however, has slowed, and has been 3.0 percent or lower since 2001. figures 2.36–37 The USRDS projects that there will be nearly 800,000 prevalent ESRD patients receiving therapy in 2020, and that more than 150,000 new patients will begin treatment that year.

2.1 Projected changes in the composition of the prevalent ESRD population to 2020, by age & race

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incidence & prevalence

n 2005 the overall adjusted incidence of ESRD again remained stable, with the rate of 347 per million popula-tion only 1 percent higher than in 2001 (Figure 2.2). In 2005, nearly 77,000 of the new ESRD patients lived in urban areas, and 26,000 in rural settings (Figure 2.3)

The overall median age of new patients has changed little since the late 1990s, and in 2005 was 64.6, with a range from 58.1 in Native Americans to 67.4 in whites (Figure 2.4).

Incident rates between 2000 and 2005 have been rela-tively steady for most age groups, changing less than 3.0 per-cent (Figure 2.5). For patients age 75 and older, however, the rate has grown 10 percent, from 1,570 to 1,725 per million.

Incident rates in Medicare Advantage (formerly Medi-care + Choice patients) were 20 percent higher in 2005 than those found in patients enrolled in a fee-for-service pro-gram (Figure 2.6).

While incident counts and rates by gender have not been changing dramatically in recent years, the gap between males

incidence

2.2 Adjusted incident rates & annual percent change incident ESRD patients 2.3 Incident counts, by geographic

location incident ESRD patients

2.4 Median age of incident patients, by race/ethnicity incident ESRD patients 2.5 Incident counts & adjusted rates,

by age incident ESRD patients

2.6 Incident rates, by payor incident ESRD patients 2.7 Incident counts & adjusted rates,

by gender incident ESRD patients

and females continues to widen (Figure 2.7). The number of males beginning ESRD therapy in 2005 was 1.2 times greater than the number of females, and their incident rate was 1.5 times higher, at 434 per million population compared to 281.

By geographic region, the highest incident rates of ESRD continue to occur in the south and southwestern portions of the country—from California east to Texas—and in the Ohio Valley (Figure 2.8). Interestingly, the area of the western Dakotas and eastern Montana, with some of the highest rates in 2000, had some of the lowest rates in 2005.

Racial disparities in ESRD incidence continue to be dramatic (Figure 2.9). Rates in 2005 ranged from 268 per million popula-tion among whites to 991 among African Americans, 516 among Native Americans and 355 among Asians—3.7, 1.9, and 1.3 times greater, respectively.

Because the most recent edition of the Medical Evidence form, released in the spring of 2005, no longer contains cate-gories for Mexican or non-Mexican ethnicity, we have revised

I

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2007 USRDS Annual Data Report

2.8 Geographic variations in adjusted incident rates (per million population), by HSA incident ESRD patients

2.9 Incident counts & adjusted rates, by race incident ESRD patients

2.10 Incident counts & adjusted rates, by Hispanic ethnicity incident ESRD patients

2.11 Incident counts & adjusted rates, by primary diagnosis incident ESRD patients

Figure 2.10 to show differences in His-panic and non-Hispanic populations. Counts of new Hispanic ESRD patients rose to nearly 12,000 in 2005, a 63 per-cent growth since 1996, when the Med-ical Evidence form first began gather-ing information on ethnicity. The 2005 incident rate for Hispanic patients was 490 per million population, 1.5 times higher than that found among non-Hispanics.

The number of patients with dia-betes as the primary cause of ESRD rose 6.6 percent between 2001 and 2005 (Figure 2.11). The incident rate of diabetic ESRD, however, has flattened since a peak in 2001, remaining at 152–153 per million population. One-third of patients start therapy with ESRD caused by hypertension; rates for these patients have been declining slightly since 2003. The largest change in rates by diagnosis has been for those with glomerulonephritis. After reaching a high of 33 per million population in the mid-1990s, the rate fell to 26.5 by 2005, with a one-year decline of nearly 6 percent after 2004. ½

all figures incident ESRD patients. ½ figure 2.2 rates adjusted for age, gender, & race. figure 2.3 location determined using ZIP code of patient residence. figure 2.5 rates adjusted for gender & race. figure 2.6 unadjusted. figure 2.7 rates adjusted for age & race. figure 2.8 by HSA; adjusted for age, gender, & race. Excludes patients residing in Puerto Rico & the Territories. figures 2.9–10 rates adjusted for age & gender. figure 2.11 rates adjusted for age, gender, & race. ½ For Hispanic patients we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race & ethnicity.

More on incident patient counts & rates: p.a, p.2–3 & p.6, Chapter Four, 8.13–14 (pediatric patients).

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incidence & prevalence

2.12 Counts of the general U.S. population, by age

2.13 Unadjusted rates of diabetes in the U.S. population, & annual percent change

he incidence of ESRD is likely to be influenced by changing demograph-ics in the general population. In this spread we present information on diabetes in the general population, and illustrate trends in incidence using two different methods.

The National Center for Health Statistics (NCHS), of the Center for Disease Control and Prevention, reports the prevalent level of diabe-tes in the country using data collected through surveillance programs from state and county departments of health. Based on these data, the incidence of diabetes in the United States has risen to 5.3 percent, with the major growth occurring in those age 45 years and older (Figures 2.13–14).

This at-risk population can be used to compute rates of incident ESRD due to diabetes—a method developed by the CDC and reported in the Morbidity and Mortality Weekly Review (MMWR, 2005). Fig-

2.14 Unadjusted rates of diabetes in the U.S. population, by age 2.15 Incident counts of ESRD patients

with diabetes as primary diagnosis

T

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2007 USRDS Annual Data Report

2.16 Adjusted incident rates of ESRD with diabetes as primary diagnosis, by age incident ESRD patients

2.18 Adjusted incident rates of ESRD with diabetes as primary diagnosis, by race incident ESRD patients

2.17 Adjusted incident rates of ESRD with diabetes as primary diagnosis, by gender incident ESRD patients

2.19 Adjusted incident rates of ESRD with diabetes as primary diagnosis, by age & race incident ESRD patients

ures 2.16–18 illustrate the differences in adjusted incident rates of ESRD caused by diabetes when these rates are calculated with either the CDC’s diabetic population or the general pop-ulation as the denominator. Using the CDC diabetic data, it appears that ESRD due to diabetes has been declining since the mid-1990s. Data reported by the USRDS, in contrast, show the rate stabilizing in most populations over the last five years.

It is important to consider the factors that may contribute to these differences. ESRD rates based on the general popula-tion would appear the most conservative, since the denomi-nator at risk is the entire U.S. population; the CDC’s diabetes population is most likely to be at risk for diabetic ESRD. In this latter population, early detection of the disease may create a lead-time bias, with newly diagnosed diabetic patients taking longer to develop ESRD since their disease is identified earlier.

With each method, however, the most important general finding centers on the slowing of rates of ESRD due to diabetes, which may reflect improved preventive care such as glycemic and blood pressure control and the treatment of hyperlipid-emia. ½

figure 2.12 data obtained from the CDC’s National Center for Health Statistics, at http://www.cdc.gov/nchs/about/major/dvs/popbridge/datadoc.htm. Esti-mates based on the April 1, 2000, resident counts of the U.S. Census Bureau. figure 2.13 data from the National Diabetes Surveillance System, at http://www.cdc.gov/diabetes/statistics/prev/national/index.htm. figure 2.14 data from the National Diabetes Surveillance System, at http://www.cdc.gov/diabetes/sta-tistics/prev/national/figage.htm. figures 2.16–19 incident ESRD patients.

872

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234 to <267below 234 (200)

833 + (937)717 to <833603 to <717

502 to <603below 502 (455)

316 + (455)244 to <316194 to <244

151 to <194below 151 (131)

ncident rates by metropolitan statistical area (MSA) for whites exceed 300 per million popula-tion in the Los Angeles, River-side-San Bernadino (California), and Houston areas; the lowest rate is found in the Tampa-St. Petersburg MSA, at 199 per mil-lion (Table 2.a). Rates for Afri-can Americans exceed 1,000 per million population in the Dallas-Fort Worth, Houston, Detroit, Phoenix, Minneapolis-St. Paul, St. Louis, Baltimore, and Cleve-land MSAs, and are highest in the Pittsburgh area, at 1,345 per

million population. Incident rates for Hispanics are highest in the Minneap-olis-Saint Paul area, at 773, while prev-alent rates exceed 5,000 per million population for those residing in the St. Louis, Missouri, area.

The relative rate of ESRD amongst white incident patients is highest in the Los Angeles and Houston areas, at 1.39 and 1.26, respectively (Table 2.b). Patients residing in the Los Angeles and Chicago areas have the highest prevalent rate, at 1.42 and 1.17, respec-tively. Incident relative rates of ESRD for African Americans are highest for those residing in and around Houston, at 1.12, while prevalent rates are high-est for those living in the Dallas-Fort-Worth areas, at 1.04.

Geographic patterns show that incident rates for whites are highest in areas of the Southwest, south Texas, and portions of the Ohio Valley, and average 381 per million population for patients residing in areas represented

incidence & prevalence

2.a Incident & prevalent rates (per million population) of ESRD, by metropolitan statistical area (MSA) & race incident & December 31 point prevalent ESRD patients, 2005

2.b Relative rate of ESRD, by metropolitan statistical area (MSA) & race incident & December 31 point prevalent ESRD patients, 2005

2.20 Geographic variations in adjusted incident rates (per million population) of ESRD, by race & HSA incident ESRD patients, 2005

White AfricanAmerican OtherMSA Incident Prevalent Incident Prevalent Incident Prevalent

New York, NY 1.09 1.03 0.78 0.73 0.73 0.69Los Angeles, CA 1.39 1.42 0.87 0.78 0.94 0.97Chicago, IL 1.17 1.17 0.95 0.91 0.68 0.78Philadelphia, PA 0.94 0.93 0.91 0.99 0.64 0.66Dallas-Fort Worth TX 0.89 1.01 1.02 1.04 0.79 0.85Miami, FL 0.84 0.82 0.74 0.70 0.56 0.66Washington, DC 0.85 0.74 0.94 0.86 0.79 0.77Houston, TX 1.26 1.14 1.12 0.97 0.62 0.64Atlanta, GA 0.88 0.80 0.91 0.88 0.80 0.63Detroit, MI 1.13 1.03 1.06 1.02 0.93 0.82

White African American Other race

I White AfricanAmerican Other HispanicMSA Inc Prev Inc Prev Inc Prev Inc PrevNew York, NY 275 1,090 794 3,614 280 1,170 377 1,496Los Angeles, CA 351 1,503 879 3,851 359 1,640 575 2,478Chicago, IL 295 1,236 963 4,485 258 1,315 501 2,077Philadelphia, PA 237 991 926 4,888 245 1,116 443 1,594Dallas-Fort Worth, TX 224 1,073 1,036 5,148 302 1,433 441 2,327Miami, FL 211 865 750 3,452 215 1,111 209 940Washington, DC 213 783 953 4,234 302 1,302 305 1,102Houston, TX 317 1,211 1,130 4,795 239 1,084 562 2,219Atlanta, GA 222 852 921 4,337 307 1,057 180 829Detroit, MI 284 1,095 1,071 5,040 357 1,391 598 1,980Boston, MA 216 962 728 3,793 389 1,304 351 1,587San Francisco-Oakland, CA 245 1,046 952 4,524 352 1,806 401 1,669Riverside-San Bernadino, CA 339 1,375 878 3,954 383 1,740 532 2,238Phoenix, AZ 278 1,108 1,033 3,788 717 3,769 602 2,438Seattle, WA 213 939 718 4,325 345 1,819 299 1,529Minneapolis-St Paul, MN 219 1,027 1,114 5,299 564 2,926 773 2,722San Diego, CA 261 1,216 868 4,495 367 1,852 567 2,616St. Louis, MO 247 1,002 1,080 5,301 * 1,006 418 5,253Baltimore, MD 265 989 1,073 4,819 224 987 261 1,584Tampa, FL 199 860 986 4,190 351 1,291 241 1,343Pittsburgh, PA 288 1,193 1,345 5,882 * 879 * 759Denver, CO 209 999 738 4,188 289 1,340 488 2,127Cleveland, OH 284 1,161 1,085 5,391 * 1,303 504 1,925Cincinnati, OH 286 1,125 980 5,416 * 1,085 * 612Portland, OR 230 1,046 753 4,512 329 1,983 399 1,842

rates of ESRD in high-density areas

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2007 USRDS Annual Data Report

2.21 Geographic variations in incident & prevalent rates (per million population) of ESRD, by MSA & race incident & December 31 point prevalent ESRD patients, 2005

Incident rates: unadjusted

Incident rates: adjusted (for age & gender)

Prevalent rates: unadjusted

by the upper quintile (Figure 2.20). Rates for African Americans are nearly three times those found in whites, and are highest in the south, mid-south, and along the Eastern Seaboard.

Figure 2.21 shows unadjusted inci-dent and prevalent rates and adjusted incident rates of ESRD by MSA. Rates are considerably higher by MSA when compared to overall rates across the country. The overall unadjusted inci-dent rate in 2005 was 347 per million population, while rates in higher den-sity areas appear to be nearly three times greater. These differences may reflect different burdens of chronic kidney disease, as well as regional dif-ferences in the use of detection efforts and treatment interventions in popula-tions at risk for kidney failure. ½

all figures & tables incident & December 31 point prevalent (Figure 2.20, incident only) ESRD patients, 2005 . ½ table 2.a adjusted for age & gen-der; race & Hispanic ethnicity are not mutually exclusive. *Values for ten or fewer patients are suppressed. table 2.b, relative rates of ESRD are based on the median rate for all MSAs. figure 2.20 HSA; adjusted for age & gender. Excludes patients residing in Puerto Rico & the Territories.

To read MSA maps

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djusted prevalence of ESRD reached 1,569 in 2005, 1.4 times greater than in 1995 (Figure 2.22). Annual growth in the rate, however, has slowed, and has been 3.0 percent or lower since 2001.

More than 350,000 prevalent patients live in urban areas, and 112,000 in areas clas-sified as rural (Figure 2.23).

The median age of prevalent patients is now 58.6, and it varies little by race or ethnicity, ranging from a low of 56.6 in African Americans to a high of 59.7 in whites (Figure 2.24).

Nearly one in five prevalent patients is age 65–74, and 16 percent are age 75 or older (Figure 2.25). The numbers of patients age 45–64 and age 75 and older have grown 32 percent since 2000; the population age 20–44, in contrast, seems to have plateaued, increasing only 5 per-cent during the same period. The preva-lent rate in 2005 topped 5,500 per mil-lion among those age 65–74, and neared 4,800 for those 75 and above. Across age

incidence & prevalenceprevalence

2.22 Adjusted prevalent rates & annual percent change December 31 point prevalent ESRD patients 2.23 Prevalent counts, by geographic

location December 31 point prev. ESRD pts

2.25 Prevalent counts & adjusted rates, by age December 31 point prevalent ESRD patients2.24 Median age of prevalent patients

December 31 point prevalent patients

2.26 Prevalent counts & adjusted rates, by gender December 31 point prevalent patients

groups, however, the one-year rate of growth was less than 3 percent.

As in the incident population, differ-ences by gender continue to grow (Figure 2.26). The number of males in the prevalent population increased 25.6 percent between 2000 and 2005, compared to 20.3 percent for females. And the prevalent rate for males grew 14.0 percent, to 1,905 per mil-lion population, while that for females rose 9.9 percent, to 1,291.

In the prevalent population, geographic variations in ESRD rates have remained quite consistent since 2000 (Figure 2.27). The highest rates continue to occur in the Dakotas and across the southern states from California to Texas. The mean rate in

the upper quintile has increased nearly 48 percent since 2000.

By race, the number of prevalent white, African American, and Native American patients rose 20–23 percent between 2000 and 2005, while the number of Asian patients grew 39 percent (Figure 2.28). The rate per million population rose nearly 15 percent for whites and 8–9 per-cent for African Americans and Asians; that for Native Americans, in contrast, fell 1.1 percent. Significant differences by race persist, with the 2005 rates per million population of 4,863 and 2,669 for African Americans and Native Americans, respec-tively, being 4.2 and 2.3 times higher than the rate of 1,151 found among whites.

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1,717 + (1,999)1,584 to <1,7171,472 to <1,5841,338 to <1,472below 1,338 (1,233)

1,208 + (1,355)1,122 to <1,2081,066 to <1,1221,003 to <1,066below 1,003 (944)

2007 USRDS Annual Data Report

2.27 Geographic variations in adjusted prevalent rates (per million population), by HSA December 31 point prevalent patients

2.28 Prevalent counts & adjusted rates, by race December 31 point prevalent patients

2.29 Prevalent counts & adjusted rates, by Hispanic ethnicity December 31 point prevalent patients

2.30 Prevalent counts & adjusted rates, by primary diagnosis December 31 point prevalent patients

As mentioned in regard to inci-dence, the 2005 revision of the Medi-cal Evidence form now eliminates the classification of Hispanic Mexican, and offers two choices of Hispanic ethnic-ity—“Not Hispanic or Latino,” and

“Hispanic or Latino.” In 2005, the preva-lence of ESRD among Hispanics was 47 percent higher than that found in non-Hispanics (Figure 2.29). And when using the new classification system, rates for Hispanics increased nearly 40 percent between 1996 and 2005, com-pared to an increase of 34 percent in the non-Hispanic population.

By primary diagnosis, adjusted rates of diabetes remain high but appear to be leveling off, as evidenced by more mod-erate growth beginning in 2000 (Figure 2.30). Rates of diabetes between 1995 and 2000, for example, increased 39 percent. Rates between 2000 and 2005, in con-trast, grew by less than half that, at 15.6 percent. In 2005, rates of diabetes stood at 578 per million population compared to rates for hypertension, glomerulo-nephritis, and cystic kidney disease, at 382.7, 254.4, and 73.3, respectively. ½

all figures December 31 point prevalent ESRD patients. ½ figure 2.22 rates adjusted for age, gender, & race. figure 2.23 location determined using ZIP code of patient residence. figure 2.25 rates adjusted for gender & race. figure 2.26 rates adjusted for age & race. figure 2.27 by HSA; adjusted for age, gen-der, & race. Excludes patients residing in Puerto Rico & the Territories. figures 2.28–29 rates adjusted for age & gender. figure 2.30 rates adjusted for age, gender, & race. ½ For Hispanic patients we pres-ent data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific ques-tions on race & ethnicity.

More on prevalent patient counts & rates: p.a, p.2–3 & p.7, Chapter Four, 8.13–14 (pediatric patients).

1995 2005

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(95% CI: $8.7 - $181.2)Actual : 2005, $21.4

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(95% CI: 246,858 - 988,414) Actual: 2005, 341,319

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(95% CI: 232,633 - 283,220) Actual : 2005, 143,693

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(95% CI: 460,374 - 1,255,436) Actual: 2005, 485,012

incidence & prevalenceprojected ESRD counts & costs through 2020

2.31 Projected counts of incident ESRD patients through 2020 (autoregression model) 2.32 Projected counts of prevalent ESRD patients

through 2020 (autoregression model)

2.33 Projected ESRD expenditures through 2020 (autoregression model)

2.34 Projected counts of prevalent dialysis patients through 2020 (autoregression model)

2.35 Projected counts of prevalent transplant patients through 2020 (autoregression model)

n published papers the USRDS has used two methods to project future ESRD counts, one with available data through 1997 and projecting to 2010 (Xue et al.), and one with available data through 2000 and projecting to 2015 (Gilbertson et al.). The first method used a forecasting methodology with a stepwise autoregressive technique and exponential smoothing, while the second was based on a Markov model. Here we revisit both methods, using data available through 2005, and projecting to 2020.

Figures 2.31 and 2.36 compare newly projected inci-dent counts to original projections, using the autore-gression and Markov models, respectively. The original autoregression projection consisted of a conservative, more linear projection (in Figure 2.31, Model 1) and a less conservative, quadratic projection (Model 2). Both overestimated actual counts in 2005, with the more con-

servative projection doing so by approximately 21 percent. The updated projection, using data through 2005, produces an estimate of 143,963, similar to the 150,772 obtained in Figure 2.36 with the Markov model. The new autoregression projec-tion produces a lower estimates for 2010 than did our previous projection. This is primarily a result of a slowing of the growth in incident counts from 2000 to 2005, itself due to continued flattening of the incident rates. This decreased growth in terms of patient counts, however, is not expected to continue, as the effect of the baby boomers, of changing patient distribution by race and ethnicity, and of a continued rise in the prevalence of diabetes will drive future increases in ESRD counts, even if there is no further growth in rates of ESRD.

Figures 2.32 and 2.37 show projected prevalent ESRD counts using the autoregression and Markov models. Similar to those of incident counts, the new projections give slightly lower estimates for 2010 than did our previous estimates. Both models project approximately 785,000 prevalent ESRD patients by 2020.

In Figure 2.33 we project total Medicare ESRD costs to 2020 (this estimate is not adjusted for inflation). With actual costs in 2005 of $21.3 billion, continued growth in ESRD counts—both prevalent and incident—is expected to double these expendi-tures before 2019, with costs of $53.6 billion in 2020.

Projected prevalent counts for the dialysis and transplant populations are shown in Figures 2.34–35 and 2.38. While new immunosuppressive drugs, improved surgical techniques, and improved post-transplant care during the past decade

I2

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Tx: 2020, 250,813; 2005, 143,693

light lines show actual counts

light lines show actual counts

light lines show actual counts

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White: 2020, 488,688; 2005, 298,064African Am.: 2020, 224,669;2005, 151,801Other: 2020, 71,2562005, 35,130

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Diabetes: 2020, 293,843;2005, 174,043Other: 2020, 490,7692005, 310,943

have enabled transplantation of older patients and of those with a higher burden of comorbidity, transplanted patients still currently account for just 30 percent of the prevalent ESRD popu-lation, primarily due to organ availabil-ity. The Markov model assumes a simi-lar distribution, with this 30 percent growing just slightly by 2020, while the autoregression model makes no such assumption and separately extrapo-lates actual dialysis and transplant counts. These methods lead to some-what different projections: for dialysis, the Markov model estimates 533,800 patients by 2020, and the autoregres-sion model 525,885. For transplant, projected counts are 250,813 and 257,927, respectively. Autoregression estimates suggest that 33 percent of prevalent ESRD patients in 2020 will have a trans-plant, and 67 percent will be treated with dialysis.

Projected incident and prevalent counts by race and primary cause of renal failure are shown in Figures 2.39–40. By race, we project that the largest percent change between 2005 and 2020 will be among patients of races other than white or African Ameri-can. In the prevalent population, for example, counts of white and African American patients are estimated to grow 64 and 48 per-cent, while the number of patients of other races is expected to more than double—from 35,130 in 2005 to 71,256 in 2020.

2007 USRDS Annual Data Report

2.36 Projected counts of incident ESRD patients through 2020 (Markov model) 2.37 Projected counts of prevalent ESRD

patients through 2020 (Markov model)

2.40 Projected growth of incident & prevalent ESRD populations through 2020, by primary diagnosis (Markov model)

2.38 Proj. growth of prev. ESRD populations, by modality (Markov model) 2.39 Projected growth of incident & prevalent ESRD

populations through 2020, by race (Markov model)

By primary cause of renal failure, continued expected growth in the prevalence of diabetes should lead to a further rise in dia-betic renal failure. We project that patients with ESRD caused by diabetes will account for 47 percent of the incident ESRD popu-lation, and 37 percent of the prevalent population, by 2020. ½

figures 2.31–32 & figures 2.34–35 counts projected using forecasting & time series analy-sis. Original projection uses two models with data from 1982 through 1997; new projection uses data from 1980 through 2005. figure 2.33 dollars projected using fore-casting & time series analysis. Original projection uses data from 1982 through 1997; new projection uses data from 1991 through 2005. figures 2.36–40 counts pro-jected using a Markov model. Original projection uses data through 2000; new projection uses data through 2005.

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n this spread we present data on the incidence and prevalence of ESRD due to some of the less frequently occurring primary diagnoses.

In 2004–2005, the incidence of ESRD caused by Fabry’s disease—a lipid storage disorder—was 0.9 per million population, and the prevalence rose slightly to 0.5 (Fig-ure 2.41).

The incidence of ESRD due to IgA nephropathy/Berger’s disease or to IgM nephropathy was stable during the late 1990s and early part of this decade, then rose slightly in 2004–2005, reaching 3.2 cases per million population (Figure 2.42). Prevalence,

in contrast, has grown steadily since 1996–1997, reaching 22.1 in 2004–2005, and indicat-

ing that people are surviving longer with these diagnoses.Rates of ESRD caused by Wegener’s granulomatosis show

a similar pattern of change (Figure 2.43). After stabilizing between 1998 and 2003, incidence rose in 2004–2005 to 1.0 per million population. Prevalence has risen steadily since 1996–1997, reaching 4.6 in 2004–2005—a growth of 70 percent.

Systemic lupus erythematosus (SLE) is an autoimmune disease in which the body produces antibodies to its own pro-teins. The incidence of ESRD due to this disease has remained between 3.4 and 3.8 per million population since 1996–1997, while prevalence has grown 46.9 percent, reaching 28.4 in 2004–2005 (Figure 2.44).

The rate of new cases of ESRD caused by secondary glomer-ulonephritis/vasculitis other than Wegener’s or SLE nephri-tis—a designation that includes scleroderma, hemolytic ure-mic syndrome, and nephropathy due to heroin or other drug abuse—has fallen very slightly, and is now 2.9 per million pop-ulation (Figure 2.45). Prevalence has grown from 13.5 in 1996–1997 to 16.4 in 2004–2005.

Polycystic kidney disease is an inherited disorder marked by numerous cysts in the kidney, and usually appears later in life. Incidence of ESRD due to PKD has been steady since the mid-1990s, at 7.4–8.0 per million population, while prevalence has increased from 58.8 to 71.1 cases per million population—growth of 20.8 percent (Figure 2.46).

The incidence of ESRD caused by Alport’s disease—also an inherited condition, marked by deafness and hematuria as well as kidney damage—and by other hereditary and familial diseases remains between 0.5–0.6 per million population, while prevalence grew slightly to reach 6.8 in 2004–2005 (Figure 2.47).

For ESRD due to multiple myeloma or light chain nephrop-athy, rates of incidence and prevalence show a similar pat-tern—peaking in 2002–2003 at 4.7 and 5.9 per million popula-tion, respectively, then falling slightly in the following two-year period (Figure 2.48).

New ESRD due to amyloidosis—in which insoluble proteins accumulate in the tissues and organs—has remained stable at 0.9 per million population since 2000, while prevalence has risen slightly from 2.0 in 1996–1997 to 2.2 in 2004–2005 (Figure 2.49).

incidence & prevalencerare diseases

2.41 Rates of ESRD due to Fabry’s disease incident & December 31 point prevalent ESRD patients

2.42 Rates of ESRD due to IgA nephropathy/Berger’s disease or IgM nephropathy incident & December 31 point prevalent ESRD patients

2.43 Rates of ESRD due to Wegener’s granulomatosis incident & December 31 point prevalent ESRD patients

OWhile the rate of new cases of ESRD due to AIDS has fallen

slightly since the beginning of the decade—reaching 2.7 per mil-lion population in the 2004–2005 period—prevalence has grown steadily, reaching 8.9 in 2004–2005, and indicating that people are living longer with the disease (Figure 2.50).

New cases of ESRD due to complications from a transplant seem to have spiked in 2004–2005, to 0.9 per million popula-tion; this growth may, however, be attributed to new codes on the revised Medical Evidence form that are related to post-trans-plant complications (Figure 2.51). Prevalence of ESRD from these complications reached 3.8 in 2004–2005. ½

figures 2.41–51 incident & December 31 point prevalent ESRD patients.

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2007 USRDS Annual Data Report

2.44 Rates of ESRD due to lupus erythematosus (SLE nephritis) incident & December 31 point prevalent ESRD patients 2.45 Rates of ESRD due to other secondary glomerulonephritis/

vasculitis incident & December 31 point prevalent ESRD patients

2.46 Rates of ESRD due to polycystic kidney disease incident & December 31 point prevalent ESRD patients 2.47 Rates of ESRD due to Alport’s & other hereditary/familial

disease incident & December 31 point prevalent ESRD patients

2.48 Rates of ESRD due to multiple myeloma & light chain nephropathy incident & December 31 point prevalent ESRD patients 2.49 Rates of ESRD due to amyloidosis incident

& December 31 point prevalent ESRD patients

2.50 Rates of ESRD due to AIDS incident & December 31 point prevalent ESRD patients 2.51 Rates of ESRD due to post-transplant (non-renal) complications

incident & December 31 point prevalent ESRD patients

952

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64.9 + (66.3)63.9 to <64.962.4 to <63.9

60.9 to <62.4below 60.9 (59.8)

59.1 + (59.8)58.4 to <59.157.7 to <58.4

57.0 to <57.7below 57.0 (56.4)

incidence & prevalenceESRD network populations

2.53 Hypertension, 1995–2005 incident ESRD patients

2.54 Glomerulonephritis, 1995–2005 incident ESRD patients

2.55 Geographic variations in mean age, by HSA & ESRD network, 2005 incident & December 31 point prevalent ESRD patients

etween 1995 and 2005, the number of new patients with diabetes as the cause of ESRD grew nearly 60 percent, and the rate per million in 2005 reached 151.9 (Figure 2.52). Network 1 exhibited the lowest rate of growth in new cases, at 33.6 percent, and Network 14 the highest, at 79.9 per-cent. Rates of diabetic ESRD range from 94.4 per million population

in Network 16 to nearly 190 in Network 14—25 percent higher than the rate for all networks combined. Rates exceeding 170 per million population are evident in Networks 5, 6, 8, 9, and 13.

The number of new ESRD cases attributed to hypertension grew 52 per-cent in 2005, while the rate per million population was 61 percent lower than that of diabetic ESRD (Figure 2.53). Network 15 shows the most significant growth in the number of new cases—91.7 percent—compared to 30.6 percent in Network 2. The rate is highest in Net-work 8, at more than 140 per million population, and lowest in Network 16, at 47.6. Rates exceeding 120 are evident in Networks 5, 6, and 13.

New cases of ESRD caused by glo-merulonephritis fell 2.3 percent overall in 2005 (Figure 2.54). Ten-year change varies widely among networks, from a rise of 23.2 percent in Network 15 to a decrease of 21.8 in Network 10. Rates per million population vary less than rates of ESRD due to diabetes or hyperten-sion, from a high of 32.7 in Network 3 to a low of 20.8 in Network 14. In Network 16, the 3.0 percent growth in 2005 is sig-nificantly less than growth rates of 58.7 and 71.6 percent, respectively, found in patients with diabetes or hypertension.

Mean age is greatest across the northern half of the country and Flor-ida (Figure 2.55). From the lower to the upper quintiles, mean age varies from 59.8 to 66.3 and 56.4 to 59.8, respectively, among incident and prevalent patients.

Tables 2.c–e present adjusted patient demographics and disease rates by modality in 2005. Rates per million for incident dialysis patients range from 221 in Network 16 to 413 in Network 8. In 11 of 18 networks the rate exceeds that of the overall population.

2.52 Diabetes, 1995–2005 incident ESRD patients

Growth in incident ESRD populations, by primary diagnosis & network

B

Incident Prevalent

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2007 USRDS Annual Data Report

2.c Patient demographics & adjusted rates, by network: incident dialysis patients, 2005 incident dialysis patients

2.d Patient demographics & adjusted rates, by network: point prevalent dialysis patients, 2005 December 31 point prevalent dialysis patients

2.e Patient demographics & adjusted rates, by network: point prevalent transplant patients, 2005 December 31 point prevalent transplant patients

2.56 ESRD networks

In the point prevalent dialysis popu-lation, rates per million range from 680 in Network 16 to 1,390 in Network 8 and 1,428 in Network 6. African Americans tend to constitute a large proportion of the patient population in networks with the highest point prevalence.

Transplant rates are highest in Net-work 11, at 713 per million population. Network 7, representing the Upper Mid-west, accounted for 11.2 percent of the total transplants performed in 2005. ½

figures 2.52–54 incident ESRD patients; rates adjusted for age, gender, & race. figure 2.55 incident & December 31 point prevalent ESRD patients, 2005, by HSA, unadjusted. Excludes patients residing in Puerto Rico & the Territories. table 2.c incident dialysis patients. table 2.d December 31 point prevalent dialysis patients. * Values for cells with ten or fewer patients are suppressed. table 2.e December 31 point prevalent transplant patients. ½ tables 2.c–e counts & percentages include all patients in each network; rates, however, are cal-culated for the U.S. population only, & exclude patients with unknown age, gender, race, or net-work. Rates adjusted for age, gender, & race. ½ A list of network contacts can be found on page 258 of Appendix A.

Total %of Rateper Mean % % % % % %Network patients total million age Diabetic White AfAm NAm Asian Hisp.1 3,771 3.6 259.7 65.9 39.1 82.5 13.6 0.2 2.8 6.52 6,947 6.7 347.3 63.8 40.6 61.0 31.7 0.4 4.4 13.53 4,603 4.4 376.1 64.3 48.8 66.4 25.8 0.2 2.9 33.84 5,109 4.9 380.3 65.1 42.4 73.4 24.9 0.1 1.1 2.55 6,311 6.0 398.3 61.9 42.7 48.5 48.2 0.2 2.3 2.66 8,776 8.4 391.9 60.1 43.7 41.6 56.0 0.7 1.2 2.07 6,498 6.2 357.1 64.0 42.0 67.1 29.6 0.3 1.6 13.38 5,649 5.4 413.1 60.5 41.2 49.3 49.1 0.4 0.6 0.79 8,204 7.9 368.7 63.9 45.9 74.9 24.0 0.1 0.5 1.710 4,517 4.3 342.1 63.0 39.7 62.3 32.5 0.1 2.5 10.111 7,234 6.9 320.7 64.0 41.8 72.0 23.5 2.5 1.6 2.912 4,047 3.9 301.2 63.8 42.1 77.1 21.0 0.7 0.9 2.813 4,238 4.1 383.9 61.7 44.1 54.9 39.3 4.4 0.8 2.414 8,332 8.0 356.9 60.2 53.2 71.5 25.6 0.4 1.7 38.415 4,584 4.4 251.1 61.2 50.7 78.5 8.8 8.9 3.3 24.016 2,903 2.8 220.9 63.5 42.4 84.0 6.1 3.3 6.3 7.017 4,957 4.7 319.9 62.2 48.0 57.6 13.6 0.9 26.1 18.818 7,808 7.5 326.8 62.1 46.1 69.4 14.9 0.5 11.3 38.8

All 104,488 100.0 340.1 62.7 44.4 65.0 28.7 1.1 3.8 13.0

Total %of Rateper Mean % % % % % %Network patients total million age Diabetic White AfAm NAm Asian Hisp.1 11,524 3.4 784 64.0 38.3 75.2 19.9 0.3 2.7 8.02 23,119 6.8 1,140 61.8 39.4 50.1 40.8 0.5 4.7 14.13 14,011 4.1 1,128 61.7 44.5 56.4 33.6 0.1 2.9 33.74 15,014 4.4 1,109 63.1 40.7 62.5 35.3 0.2 1.1 3.35 20,649 6.1 1,291 60.1 39.3 36.9 59.3 0.1 2.3 2.86 32,456 9.5 1,428 58.5 40.8 30.3 67.2 0.6 0.9 2.37 19,456 5.7 1,051 61.3 39.4 55.5 40.9 0.2 1.8 14.58 19,086 5.6 1,390 58.7 39.6 36.8 62.0 0.4 0.5 0.79 24,811 7.3 1,112 61.7 43.6 64.4 34.3 0.1 0.6 2.110 14,523 4.3 1,108 61.5 38.9 53.8 41.7 0.1 2.8 10.911 21,488 6.3 949 62.6 41.4 62.2 32.0 3.2 2.1 3.712 12,784 3.8 946 61.9 40.9 67.7 29.8 1.1 1.2 5.613 13,354 3.9 1,204 59.2 42.5 42.7 51.0 5.0 0.8 2.414 29,904 8.8 1,262 58.7 51.3 65.4 31.0 0.3 1.8 41.715 15,267 4.5 824 60.5 51.8 71.0 10.5 14.3 3.5 28.116 9,020 2.6 680 61.4 41.7 77.9 9.3 4.5 8.0 8.617 17,709 5.2 1,119 61.2 46.9 49.0 16.7 1.0 30.5 21.018 27,143 8.0 1,158 60.4 45.2 68.0 17.2 0.5 12.6 43.0Unknown * All 341,319 100.0 1,103 60.8 42.9 55.3 37.2 1.5 4.4 14.8

Total %of Rateper Mean % % % % % %Network patients total million age Diabetic White AfAm NAm Asian Hisp.1 7,125 5.0 484.9 50.3 20.1 84.3 11.6 0.2 2.9 7.22 8,708 6.1 434.3 49.4 18.6 69.9 21.5 0.6 5.4 16.43 4,002 2.8 368.0 49.5 21.1 72.6 20.4 0.2 4.3 29.54 8,636 6.0 628.4 50.2 22.2 74.7 20.8 0.2 2.4 2.55 8,834 6.2 546.6 50.1 22.2 58.5 35.4 0.2 4.0 4.76 8,329 5.8 369.9 48.6 21.9 59.9 37.3 0.7 1.7 2.17 7,173 5.0 384.8 51.0 21.2 73.3 22.2 0.3 3.0 16.08 6,784 4.7 492.3 48.3 20.2 66.7 31.5 0.2 0.9 0.99 10,469 7.3 465.0 49.4 24.7 81.2 16.1 0.1 1.4 1.510 6,292 4.4 466.6 48.5 22.1 67.8 24.8 0.2 3.8 12.111 16,131 11.2 712.7 50.0 28.4 83.4 11.8 1.7 2.6 3.112 6,599 4.6 487.6 49.3 22.8 84.2 12.6 1.0 1.7 4.813 4,455 3.1 401.9 48.6 23.4 63.2 32.1 2.9 1.4 2.114 9,675 6.7 402.9 48.7 24.2 78.9 16.2 0.4 3.3 35.315 7,061 4.9 383.1 49.2 28.0 85.0 5.2 5.8 3.6 19.816 5,533 3.9 418.3 50.1 25.6 84.3 5.3 3.0 7.3 6.217 7,372 5.1 479.6 49.1 20.1 66.2 8.9 1.0 21.9 19.318 10,324 7.2 439.3 48.5 19.8 74.5 10.7 0.6 13.0 36.3Unknown 191 0.1 . 47.9 0.0 23.6 1.6 0.5 7.3 1.1All 143,693 100.0 466.2 49.4 22.9 74.4 18.6 1.0 4.7 12.0

More on network populations: 10.3 & 10.6.

Network1 Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont

Network2 New YorkNetwork3 New Jersey, Puerto Rico, Virgin IslandsNetwork4 Delaware, Pennsylvania Network5Maryland, Virginia, Washington D.C.,

West VirginiaNetwork6 Georgia, North Carolina, South

Carolina Network7 Florida Network8 Alabama, Mississippi, Tennessee Network9 Indiana, Kentucky, OhioNetwork10 IllinoisNetwork11 Michigan, Minnesota, North Dakota,

South Dakota, Wisconsin Network12 Iowa, Kansas, Missouri, NebraskaNetwork13 Arkansas, Louisiana, OklahomaNetwork14 TexasNetwork15 Arizona, Colorado, Nevada, New

Mexico, Utah, WyomingNetwork16 Alaska, Idaho, Montana, Oregon,

WashingtonNetwork17 American Samoa, Northern

California, Guam, Hawaii Network18 Southern California

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incidence & prevalence

incidencefigure 2.2 In 2005, the overall adjusted incidence of ESRD again re-mained stable, with the rate of 347 per million population only 1 per-cent higher than in 2001. figure 2.9 Racial disparities in the incidence of ESRD continue to be dramatic. Incident rates in 2005 ranged from 268 per million population among whites to 991 among African Americans, 516 among Native Americans, and 355 among Asians—3.7, 1.9, and 1.3 times greater, respectively. figure 2.10 The 2005 incident rate for Hispanic patients was 490 per million population, 1.5 times higher than that found among whites.

incident rates of ESRD based on at-risk populationsfigures 2.13–14 Based on data collected through surveillance programs, the incidence of diabetes in the United States has risen to 5.3 per 100 population, with the major growth occurring in those age 45 years and older. figures 2.16–18 Using the CDC diabetic data, it appears that ESRD due to diabetes has been declining since the mid-1990s. Data reported by the USRDS, in contrast, show the rate stabliliz-ing in most populations over the last five years. With each method, however, the most important general finding centers on the slow-ing of rates of ESRD due to diabetes, which may reflect improved preventive care.

ESRD rates in high-density areastable 2.a Incident rates by Metropolitan Statistical Area for whites ex-ceed 300 per million population in the Los Angeles, Riverside-San Bernadino (California), and Houston areas, while the lowest rates are found in patients living in the Tampa-St. Petersburg area, at 199 per million. figure 2.20 Geographic patterns show that incident rates for whites are highest in areas of the Southwest, south Texas, and por-tions of the Ohio Valley, and average 381 per million population for patients residing in areas represented by the upper quintile. Rates for African Americans are nearly three times those found in whites, and are highest in the south, mid-south, and along the Eastern Seaboard.

prevalencefigure 2.22 The adjusted prevalence of ESRD reached 1,569 per million population in 2005, 1.4 times higher than in 1995. Annual growth in the rate, however, has slowed, and has been 3.0 percent or lower since 2001. figure 2.25 The numbers of patients age 45–64 and age 75 and older have grown 32 percent since 2000; the population age 20–44, in contrast, seems to have plateaued, increasing only 5 per-cent during the same period. figure 2.28 Significant racial differences in ESRD prevalence persist, with the 2005 prevalent rates per mil-lion population of 4,863 and 2,669 for African Americans and Native Americans, respectively, being 4.2 and 2.3 times higher than the rate of 1,151 found among whites.

projections of counts & costs of ESRDfigures 2.31 & 2.36 Updated projections of incident counts of ESRD through the year 2020, using the au-toregression and Markov analytical models, show similar results of 143,693 and 150,722, respectively. figures 2.32 & 2.37 Using the autoregression and Markov models, projected preva-lent counts of ESRD through 2020 are approximately 785,000. figure 2.33 Projected Medicare ESRD costs in 2020 are approximately $53.6 billion dollars.

rare diseasesfigure 2.42 The prevalence of ESRD due to IgA nephropathy/Berger’s disease or IgM nephropathy has grown steadily since 1996–1997, reaching 22.1 per million population in 2004–2005, and indicating that people are surviving longer with the disease. figure 2.44 The inci-dence of ESRD due to systemic lupus erythematosus has remained between 3.4 and 3.8 per million population since 1996–1997, while prevalence has grown 46.9 percent, reaching 28.4 in 2004–2005.

ESRD network populationsfigure 2.52 Rates of diabetic ESRD per million population range from 94.4 in Network 16 to nearly 190 in Network 14—25 percent higher than the rate for all networks combined. figure 2.53 The rate of new ESRD cases attributed to hypertension is highest in Network 8, at more than 140 per million population, and lowest in Network 16, at 47.6. figure 2.54 Rates per million population of ESRD caused by glomerulonephritis vary less than rates of ESRD due to diabetes or hypertension, from a high of 32.5 in Network 4 to a low of 20.8 in Network 14. table 2.e By network, transplant rates are highest in Net-work 11, at 713 per million population.

chapter summary

maps National means & patient populations for maps can be found in the Excel file for this chapter—on our website at www.usrds.org, & also on the CD-ROM included at the back of this book.

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