The incidence of end-stage renal disease is increasing faster than the prevalence of chronic renal insufficiency

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.