# ![](media/image1.wmf){width="2.3986111111111112in" height="2.2930555555555556in"} {#section .Chapter-#}

# 4 {#section-1 .Chapter-#}

# Chronic Kidney Disease

Lead Agency: National Institutes of Health

### Contents {#contents .Heading-Special}

[Goal Page 4-3](#goal)

[Overview Page 4-3](#overview)

[Issues and Trends Page 4-3](#issues-and-trends)

[Disparities Page 4-5](#disparities)

[Opportunities Page 4-7](#opportunities)

[Interim Progress Toward Year 2000 Objectives Page
4-8](#interim-progress-toward-year-2000-objectives)

[Healthy People 2010---Summary of Objectives Page
4-9](#healthy-people-2010summary-of-objectives)

[Healthy People 2010 Objectives Page
4-10](#healthy-people-2010-objectives)

[Related Objectives From Other Focus Areas Page
4-20](#related-objectives-from-other-focus-areas)

[Terminology Page 4-23](#terminology)

[References Page 4-25](#references)

##   {#section-2 .unnumbered}

## Goal

Reduce new cases of chronic kidney disease and its\
complications, disability, death, and economic costs.

## Overview

### Issues and Trends

Chronic kidney failure is the most significant result of chronic kidney
disease. When kidney function has deteriorated and is no longer adequate
to sustain life and the process is considered irreversible, renal
replacement therapy (RRT)---dialysis or transplantation---becomes
necessary to maintain life. Treated chronic kidney failure, also called
end-stage renal disease (ESRD), is the most feared consequence of kidney
disease. Chronic renal insufficiency, however, is more common than
treated chronic kidney failure and can also severely affect health and
well-being. Therefore, ideally, programs should be directed at
preventing the development of chronic renal insufficiency and its
subsequent progression to ESRD.

Unfortunately, chronic renal insufficiency is usually asymptomatic, and
the exact number of people affected is unknown. The best available
estimates are based on national surveys. Current estimates indicate
approximately 10 million persons aged 12 years and older have some form
of chronic kidney disease.[^1] People with end-stage kidney failure
represent a small fraction of all individuals with chronic kidney
disease. A significant proportion of people with chronic kidney failure
progress to end stage. The challenge is to initiate effective programs
to prevent progression of established kidney disease and to institute
methods to assess the progress of such
initiatives.![](media/image2.wmf){width="4.497222222222222in"
height="3.5618055555555554in"}

In 1997, 80,248 new cases of end-stage kidney failure were reported.[^2]
Virtually all of these patients became permanently dependent on renal
replacement therapy to stay alive.

Dialysis and kidney transplantation are the two methods of treatment
available to people with kidney disease when they reach end stage. In
1997, 361,031 people in the United States depended on either dialysis or
transplants to replace the function of their own failed kidneys.[^3]
Although these treatments are lifesaving, dialysis and transplants have
substantial limitations. Neither treatment restores normal health, and
both are expensive.[^4] The rates of illness, disability, and death
experienced by individuals with treated chronic kidney failure are
substantially higher than those of the general population.[^5]

In most instances, terminal kidney failure develops as the result of
progressive damage to the kidneys over a decade or more. A number of
underlying diseases can cause progressive kidney failure. The two most
important of these are diabetes, which in 1997 accounted for 42 percent
of the new cases of chronic kidney failure, and high blood pressure,
which was responsible for 26 percent of the new cases.[^6] Other
conditions that contribute significantly include glomerulonephritis,
vasculitis, interstitial nephritis, and genetic and congenital
disorders, particularly polycystic kidney disease.[^7]

Chronic kidney failure affects people of all ages. The number of new
cases peaks in the sixth decade of life, but 25 percent of persons
arriving at end stage in 1997 were under age 45 years, and 1.5
percent---nearly 1,100---were under age 20 years.Error: Reference source
not found Kidney failure is particularly devastating in childhood, often
resulting in impaired growth and development.

A worrisome increase in the number of new cases of kidney failure
occurred between 1987 and 1997. The rate increased from 142 per million
population in 1987 to 296 per million population in 1997,[^8]
representing an increase in the annual number of new cases from 34,797
to 80,248,[^9] respectively.

This relentless growth in new cases of kidney failure has occurred in
spite of the fact that death rates from other diseases, especially
cardiovascular diseases, have declined.[^10] The increase has not been
confined to a single age group. Although the rates of new cases have
grown slightly more rapidly for individuals aged 75 years and older,
sizable increases have been noted in every age group.[^11]

The causes of these increases are not completely understood, but one
major factor appears to be an increase in the number of new cases of
diabetes, particularly type 2 diabetes.[^12]**^,^** [^13] In 1987, the
rate of new cases of treated chronic kidney failure due to diabetes was
45 per million population. By 1997, the rate had increased to 124 per
million population.[^14]

Treatment for end-stage kidney failure has a substantial impact on
Federal resources for health care. The 1972 Social Security Amendment
(Public Law 92-603) instituted federally financed health care coverage
for dialysis and renal transplantation, effective July 1, 1973. The cost
of this program has far exceeded original expectations. Medicare
spending in 1996 was estimated to be \$10.96 billion, a 12.5 percent
increase from the \$9.74 billion spent in 1995. The total expenditure by
all payers for treating these patients in 1996 was estimated at \$14.55
billion, up from \$13.05 billion in 1995.[^15] Although this patient
population made up only 0.6 percent of the total Medicare population in
1994, it consumed 5.1 percent of Medicare expenditures.[^16] The
increases in the cost per patient have been modest, but the driving
force behind the growth in these expenditures has been the growing
number of patients.

Kidney disease develops and progresses more rapidly to end stage in
people with chronic health problems (such as type 1 or type 2 diabetes
or high blood pressure) or with a family history of genetic kidney
diseases. Therefore, people with these chronic health problems require
counseling about the possibility of kidney disease and the steps they
must take to avoid serious kidney complications. Also, people who have
proteinuria and/or elevated serum creatinine have a greater likelihood
of developing serious cardiovascular disease (CVD) complications.
Therefore, cardiovascular risk assessment and management should include
kidney function to prevent the consequences of kidney failure. Because
national data systems will not be available in the first half of the
decade to track progress, these issues are not addressed in the chapter.

### Disparities

Kidney disease has a disproportionate impact on certain racial and
ethnic groups, especially African Americans and American Indians or
Alaska Natives. African Americans have the highest overall risk of
chronic kidney disease. The reasons are not entirely explained by the
higher number of persons in this population who have diabetes and high
blood pressure.[^17]**^,^** [^18] On average, African Americans develop
end-stage kidney failure at an earlier age than whites (55.8 years
compared to 62.2 years).[^19] American Indians or Alaska Natives have a
much higher risk of chronic kidney disease due to diabetes than whites.
Overall, the rates of new cases are 4 times higher in African Americans
and American Indians or Alaska Natives and 1.5 times higher in Asians or
Pacific Islanders than in whites.

Annual increases in ESRD rates are greater in certain racial and ethnic
populations than in white populations. Rates of new cases are increasing
by 7 percent per year for African Americans, 10 percent per year for
American Indians or Alaska Natives, and 11 percent for Asians or Pacific
Islanders, compared to 6 percent per year for whites. Two communities of
an American Indian Tribe, the Zuni Pueblo in New Mexico and in Sacaton,
Arizona, may have the highest rates of chronic kidney failure in the
world, at 12.6 and 14.0 times the overall average U.S. rate,
respectively. Projections indicate that increases in the rates of new
cases will continue in American Indians or Alaska Natives.

Although complete data are not yet available, some evidence indicates
that persons of Mexican ancestry also may have a high risk of developing
chronic kidney failure, particularly due to diabetes.[^20]**^,^** [^21]
In 1995, the Health Care Financing Administration changed the way in
which data on race and ethnicity are collected on the Medical Evidence
Form used to enroll patients into the Medicare End-Stage Renal Disease
Program. Data from 1997 suggest that 7 percent of the ESRD patients are
of Mexican ancestry and another 4 percent are of Hispanic ancestry from
areas other than Mexico.[^22]

The disproportionately high rates of chronic kidney failure among
certain racial and ethnic groups have resulted in a greater burden of
disease in these communities. In 1996, African Americans constituted
12.6 percent of the U.S. population but 29.8 percent of ESRD patients;
American Indians or Alaska Natives constituted 0.9 percent of the U.S.
population but 1.7 percent of those receiving renal replacement
therapy.[^23] On December 31, 1996, the point-prevalent rate per million
population (adjusted for age and gender) was 3,404 in African Americans
and 2,761 in American Indians or Alaska Natives, compared to 754 in
whites, differences of 4.5- and 3.7-fold, respectively.[^24] Data on
persons of Asian or Pacific Islander ancestry indicate slightly higher
incidence and prevalence rates than those for whites.[^25]

There is a slight preponderance of kidney failure in men. In 1997, the
incidence of treated chronic kidney failure was 322 per million
population in men, compared with 271 per million in women.Error:
Reference source not found

Renal transplantation is an important lifesaving renal replacement
therapy and has been shown to offer many advantages when compared with
dialysis.[^26]**^,^** [^27] In 1997, 12,445 transplants were performed
in the United States. There was significant gender discrepancy, with
7,352 transplants for men, compared with 4,948 for women.[^28] Racial
and ethnic disparities also exist. Between 1994 and 1997, the first
cadaveric transplantation rates (per 100 patient years) in the pediatric
age group were 31 for black males, 28 for white males, 19 for black
females, and 26 for white females. For recipients between the ages of 20
and 44 years, the rates were 7 for black males, 17 for white males, 7
for black females, and 15 for white females. In the 45- to 65-year age
group, the rates were 4 for black males, 8 for white males, 2 for black
females, and 6 for white females.[^29] The data from the U.S. Renal Data
System (USRDS) database also confirm that the transplantation rate is
lower for Native Americans. The transplantation rate in Asians is
equivalent to the rate in whites.[^30] Reasons for the racial and ethnic
disparities in the rate of transplantation are varied and include
differences in finding human leukocyte antigen matches, cultural
attitudes and beliefs on the part of both patients and health care
providers, socioeconomic status, rates of organ donation, and geographic
location.

### Opportunities

Major risk factors for the development and progression of chronic kidney
disease include diabetes, high blood pressure, environmental exposures,
proteinuria, family history of kidney disease, and increasing age.
African Americans and American Indians or Alaska Natives who have these
risk factors are especially susceptible to the development of chronic
and progressive kidney disease.[^31]**^,^** [^32] Strategies for
preventing the development of chronic kidney disease, therefore, should
use appropriate methods to target these populations.

Under certain circumstances, the progression of kidney disease to end
stage can be slowed or halted. Three interventions are effective in
certain defined populations: glycemic control (for patients with
diabetes), blood pressure control (for patients with high blood
pressure), and use of angiotensin-converting enzyme (ACE) inhibitors.
Interventions to slow the progression of kidney disease and prevent
chronic kidney failure are likely to have the greatest impact if applied
early in the course of the disease. Unfortunately, because kidney
disease in its early stages is generally asymptomatic, many people who
would benefit from these interventions are not identified. Early
identification of patients at risk for chronic kidney disease is
essential in reducing the growth in the number of new cases of treated
chronic kidney failure. For example, microalbuminuria screening and more
intensive treatment of patients with microalbuminuria are an important
part of a strategy to reduce nephropathy in persons with type 1
diabetes, both in terms of economic indices and clinical
outcomes.[^33]**^,^** [^34]**^,^** [^35] This strategy also may be
useful in type 2 diabetes.

Patient care must continue to emphasize interventions to conserve
residual renal function. At a certain stage, however, providing
appropriate preparation for renal replacement therapy becomes advisable.
Several studies show that many patients with chronic kidney failure do
not receive optimum preparation for treated chronic kidney failure in
the year prior to the commencement of RRT. This lack of optimal
preparation has a substantial effect on the cost of care and on illness
and disability at the time of RRT.[^36]

Kidney transplantation has emerged as the preferred therapy for many
patients with treated chronic kidney failure, particularly children.
Kidney transplantation confers a survival advantage over dialysis.[^37]
Over the past decade, transplantation success rates, especially 1-year
patient and graft survival, have improved steadily. This improvement has
been observed in both cadaveric and living-related
transplants.[^38]**^,^** [^39] For young children, kidney
transplantation results in improved rates of growth.[^40] Because of
accumulating evidence on the advantages of transplantation, equal access
of all population groups to transplantation is a substantial concern.
Certain racial and ethnic groups and women consistently have longer
waiting times and lower rates of kidney transplantation than white
males.[^41]**^,^** [^42]**^,^** [^43]**^,^** [^44]**^,^** [^45]**^,^**
[^46]

Attention to risk factors for kidney disease and interventions to slow
its progression are urgently needed. This need is driven by the
increasing number of cases of treated chronic kidney failure, its
disproportionate effect on certain racial and ethnic groups, the high
societal cost of the disease, and the impact on Federal health care
resources.

## Interim Progress Toward Year 2000 Objectives

Healthy People 2000 did not include a chapter on chronic kidney disease.
However, objectives relating to chronic kidney disease were included in
several chapters. Since the mid-1980s, the number of new cases of ESRD
has grown steadily. One objective concerning diabetes addressed ESRD.
Results show that ESRD among people with diabetes has more than doubled
since 1987 and is moving away from the target. Subobjectives tracking
ESRD due to diabetes among African Americans and American Indians or
Alaska Natives also are moving away from their targets.

Note: Unless otherwise noted, data are from the Centers for Disease
Control and\
Prevention, National Center for Health Statistics, *Healthy People 2000
Review, 1998--99.*

## Healthy People 2010---Summary of Objectives

### Chronic Kidney Disease {#chronic-kidney-disease-1 .Heading-Special-Sub}

**Goal:** Reduce new cases of chronic kidney disease and its
complications, disability, death, and economic costs.

  ------------ -------------------------------------------------------------
  **Number**   **Objective Short Title**

  4-1          End-stage renal disease

  4-2          Cardiovascular disease deaths in persons with chronic\
               kidney failure

  4-3          Counseling for chronic kidney failure care

  4-4          Use of arteriovenous fistulas

  4-5          Registration for kidney transplantation

  4-6          Waiting time for kidney transplantation

  4-7          Kidney failure due to diabetes

  4-8          Medical therapy for persons with diabetes and proteinuria
  ------------ -------------------------------------------------------------

## Healthy People 2010 Objectives

4-1. Reduce the rate of new cases of end-stage renal disease (ESRD).

**Target:** 217 new cases per million population.

**Baseline:** 289 new cases of end-stage renal disease per million
population were reported in 1997.

**Target setting method:** Better than the best.

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Total Population, 1997**                     | **New Cases of      |
|                                                | End-Stage Renal\    |
|                                                | Disease**           |
+================================================+=====================+
|                                                | Rate per Million    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 289                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 586                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 344                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 873                 |
+------------------------------------------------+---------------------+
| > White                                        | 218                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DNA                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 242                 |
+------------------------------------------------+---------------------+
| > Male                                         | 348                 |
+------------------------------------------------+---------------------+
| ###### Family income level                     |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Age groups                                     |                     |
+------------------------------------------------+---------------------+
| > Under 20 years                               | 13                  |
+------------------------------------------------+---------------------+
| > 20 to 44 years                               | 109                 |
+------------------------------------------------+---------------------+
| > 45 to 64 years                               | 545                 |
+------------------------------------------------+---------------------+
| > 65 to 74 years                               | 1,296               |
+------------------------------------------------+---------------------+
| > 75 years and older                           | 1,292               |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

The current average annual increase in new cases of treated chronic
kidney failure rates is 6 percent. Therefore, the expected rate in 2010
would be 612 new cases per million population. Without improvements in
prevention and because of changes in demographics and increases in the
number of cases of diabetes, rates of new cases of treated chronic
kidney failure are expected to continue to rise 5 to 8 percent per year.

4-2. Reduce deaths from cardiovascular disease in persons with chronic
kidney failure.

**Target:** 52 deaths per 1,000 patient years at risk.

**Baseline:** 70 deaths from cardiovascular disease per 1,000 patient
years at risk (in persons with ESRD) occurred in 1997.

**Target setting method:** Better than the best.

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Persons With Treated Chronic Kidney\         | **Deaths From\      |
| Failure, 1997**                                | Cardiovascular      |
|                                                | Disease**           |
+================================================+=====================+
|                                                | Per 1,000 Patient   |
|                                                | Years at Risk       |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 70                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 63                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 60                  |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 62                  |
+------------------------------------------------+---------------------+
| > White                                        | 75                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DNA                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 73                  |
+------------------------------------------------+---------------------+
| > Male                                         | 67                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Cardiovascular disease is the major cause of death among patients with
chronic renal failure and ESRD. Therefore, targeting reduction in CVD
deaths will lead to a significant decrease in deaths for this
population. The increased risk of CVD in kidney disease patients is
evident before the onset of terminal kidney failure. Increases in the
number of CVD deaths also are seen in individuals with proteinuria or
elevated creatinine (both are markers of declining kidney function). CVD
death rates in the treated chronic kidney failure population are
estimated to be 30-fold higher than in the general population.[^47] The
known risk factors for CVD in the general population include age, male
gender, diabetes, elevated cholesterol, high blood pressure, smoking,
and family history. Elevated homocysteine levels in the blood also may
be an important risk factor in treated chronic kidney failure patients
and at earlier stages in the progression of kidney disease.[^48]**^,^**
[^49]**^,^** [^50] Strategies to reduce CVD deaths should target risk
reduction before terminal kidney failure.[^51] All responsible health
care providers can initiate the strategies to reduce CVD deaths as
suggested in published guidelines.Error: Reference source not found

4-3. Increase the proportion of treated chronic kidney failure patients
who have received counseling on nutrition,\
treatment choices, and cardiovascular care 12 months\
before the start of renal replacement therapy.

**Target:** 60 percent.

**Baseline:** 45 percent of newly diagnosed patients with treated
chronic kidney failure received counseling on nutrition, treatment
choices, and cardiovascular care in 1996.

**Target setting method:** 33 percent improvement. (Better than the best
will be used when data are available.)

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

+----------------------------------------------+-----------------------+
| **Newly Diagnosed Patients With Treated      | **Received Counseling |
| Chronic Kidney Failure, 1996**               | Prior to Renal\       |
|                                              | Replacement\          |
|                                              | Therapy**             |
+==============================================+=======================+
|                                              | Percent               |
+----------------------------------------------+-----------------------+
| > **TOTAL**                                  | 45                    |
+----------------------------------------------+-----------------------+
| **Race and ethnicity**                       |                       |
+----------------------------------------------+-----------------------+
| > American Indian or Alaska Native           | DNA                   |
+----------------------------------------------+-----------------------+
| > Asian or Pacific Islander                  | DNA                   |
+----------------------------------------------+-----------------------+
| > Asian                                      | DNC                   |
+----------------------------------------------+-----------------------+
| > Native Hawaiian and other Pacific Islander | DNC                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | DNA                   |
+----------------------------------------------+-----------------------+
| > White                                      | DNA                   |
+----------------------------------------------+-----------------------+
|                                              |                       |
+----------------------------------------------+-----------------------+
| > Hispanic or Latino                         | DNA                   |
+----------------------------------------------+-----------------------+
| > Not Hispanic or Latino                     | DNA                   |
+----------------------------------------------+-----------------------+
| > Black or African American                  | DNA                   |
+----------------------------------------------+-----------------------+
| > White                                      | DNA                   |
+----------------------------------------------+-----------------------+
| **Gender**                                   |                       |
+----------------------------------------------+-----------------------+
| > Female                                     | DNA                   |
+----------------------------------------------+-----------------------+
| > Male                                       | DNA                   |
+----------------------------------------------+-----------------------+
| **Family income level**                      |                       |
+----------------------------------------------+-----------------------+
| > Poor                                       | DNC                   |
+----------------------------------------------+-----------------------+
| > Near poor                                  | DNC                   |
+----------------------------------------------+-----------------------+
| > Middle/high income                         | DNC                   |
+----------------------------------------------+-----------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Medically appropriate care of kidney disease patients within 12 months
before the start of renal replacement therapy reduces the substantial
illness, disability, and death associated with treated chronic kidney
failure.[^52] Appropriate preparation for RRT includes reduction in CVD
risk factors, treatment of anemia, optimum therapy to preserve residual
renal function, consultation about nutrition, and patient education
about RRT methods. Patients should be seen by a specialist in RRT at
least 12 months prior to initiation of RRT for general counseling.
However, specific issues---such as vascular access and estimation of
residual renal function---need to be addressed at least 6 months prior
to RRT. Many patients with chronic renal failure are not seen by health
care professionals who have RRT expertise until very near the time that
RRT will be required. In a USRDS survey of 3,468 new dialysis patients,
55 percent had not been seen by a nephrologist 1 year prior to the start
of RRT, and 33 percent had not been seen even 3 months before RRT.[^53]
Although control of diet is a major aspect of care for patients with
chronic kidney failure and terminal kidney failure, by the start of RRT,
46 percent of the patients had not seen a dietitian.

4-4. Increase the proportion of new hemodialysis patients\
who use arteriovenous fistulas as the primary mode\
of vascular access.

**Target:** 50 percent.

**Baseline:** 29 percent of newly diagnosed patients with treated
chronic kidney failure on hemodialysis used arteriovenous fistulas as
the primary mode of\
vascular access in 1997.

**Target setting method:** 72 percent improvement (consistent with
Dialysis\
Outcomes Quality Initiative \[DOQI\] guidelines). (Better than the best
will be used when data are available.)

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Newly Diagnosed Patients With Treated        | **Arteriovenous\    |
| Chronic Kidney Failure on Hemodialysis, 1997** | Fistula Use**       |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 29                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | DNA                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DNA                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DNA                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | DNA                 |
+------------------------------------------------+---------------------+
| > Male                                         | DNA                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Patients receiving renal replacement therapy as of December 31, 1997,
were treated predominantly (72 percent) with dialysis. Of these, 88
percent were on hemodialysis. Vascular access is the major lifeline for
hemodialysis patients. The presence of a functioning vascular access
site represents a critical factor in the well-being of these patients.
Unfortunately, however, it also is the largest single cause of illness
and disability in patients receiving hemodialysis for renal replacement
therapy, accounting for nearly 25 percent of all hospitalizations.
Complications and problems related to vascular access have been
estimated to account for as much as 17 percent of the health care costs
associated with treated chronic kidney failure.[^54]

Monitoring the type of vascular access for dialysis in new patients is
an important method to assess the adequacy of preparation for RRT.
Clinical evidence shows that patients with endogenous arteriovenous
fistulas experience lower complication rates than patients with
synthetic grafts. In the United States, the use rate for arteriovenous
fistulas is under 30 percent.[^55] Arteriovenous fistulas, ideally,
should be placed at least 6 months before the start of dialysis. Early
placement of arteriovenous fistulas is particularly important for
elderly persons, because atherosclerotic vessels may take a much longer
time to dilate to a usable diameter.

4-5. Increase the proportion of dialysis patients registered\
on the waiting list for transplantation.

**Target:** 66 percent of dialysis patients.

**Baseline:** 20 percent of newly diagnosed treated chronic kidney
failure patients under age 70 years were registered on the waiting list
in 1994--96.

**Target setting method:** Better than the best.

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

+------------------------------------------------+---------------------+
| **Dialysis Patients Under Age 70 Years,\       | **Transplant\       |
| 1994--96**                                     | Waiting List**      |
+================================================+=====================+
|                                                | Percent             |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 20                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 2                   |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 4                   |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 29                  |
+------------------------------------------------+---------------------+
| > White                                        | 65                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | 12                  |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| **Gender**                                     |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 40                  |
+------------------------------------------------+---------------------+
| > Male                                         | 60                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Age groups                                     |                     |
+------------------------------------------------+---------------------+
| > Under 20 years                               | 3                   |
+------------------------------------------------+---------------------+
| > 20 to 39 years                               | 31                  |
+------------------------------------------------+---------------------+
| > 40 to 59 years                               | 51                  |
+------------------------------------------------+---------------------+
| > 60 to 69 years                               | 15                  |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Successful renal transplantation confers many advantages, including
improvements in physical and psychological growth in children and
improved survival and quality of life for recipients in general. The
prospects of receiving a kidney transplant, however, are determined by a
number of factors. These factors include age, primary cause of kidney
failure, race and ethnic origin, gender, geographic location, and
availability of suitable donors. Any combination of these factors may
directly influence the first important step in the process of receiving
a kidney transplant---namely, being registered on the waiting list.
Significant disparities exist in the people who are registered on the
waiting list. Women and people from certain racial and ethnic
groups---particularly, African Americans---are less likely than other
kidney transplant candidates to be registered on the waiting list.Error:
Reference source not
found**^,\ Error:\ Reference\ source\ not\ found,^** [^56]

4-6. Increase the proportion of patients with treated chronic kidney
failure who receive a transplant within 3 years of registration on the
waiting list.

**Target:** 51 registrants per 1,000 patient years at risk.

**Baseline:** 41 registrants per 1,000 patient years at risk (since
placed on dialysis) received a transplant within 3 years in 1995--97.

**Target setting method:** Better than the best.

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

Data Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Renal Transplant Waiting List Registrants,   | **Transplant Within |
| 1995--97**                                     | 3 Years**           |
+================================================+=====================+
|                                                | Rate per 1,000\     |
|                                                | Patient Years       |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 41                  |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 30                  |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | DNA                 |
+------------------------------------------------+---------------------+
| > Asian                                        | 50                  |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 30                  |
+------------------------------------------------+---------------------+
| > White                                        | 49                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DNA                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| ###### Gender                                  |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 33                  |
+------------------------------------------------+---------------------+
| > Male                                         | 49                  |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Age groups                                     |                     |
+------------------------------------------------+---------------------+
| > Under 20 years                               | 282                 |
+------------------------------------------------+---------------------+
| > 20 to 44 years                               | 110                 |
+------------------------------------------------+---------------------+
| > 45 to 64 years                               | 52                  |
+------------------------------------------------+---------------------+
| > 65 years and older                           | 6                   |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Individuals from certain racial and ethnic populations (specifically,
African Americans) move up the waiting list to receive kidney
transplants at a slower rate than whites.[^57]**^,^** [^58] The exact
causes are unclear. Racial and ethnic disparities in waiting times may
be influenced by genetic and biological factors (such as HLA
types),[^59] the request and consent procedures of organ procurement
organizations, patient registration practices for a center or region,
organ acceptance practices at each transplant center, geographic
location, socioeconomic status, cultural attitudes and beliefs about
organ donation, rates of organ donation within each local area, and the
donor pool.Error: Reference source not found**^,^** [^60]

Reports also have documented a lower rate of transplantation in
women.Error: Reference source not found The U.S. Department of Health
and Human Services (HHS) is working toward the goal of making sure that
all persons in the United States have an equal opportunity to receive a
transplant, regardless of who they are or where they live. To increase
access to transplantation, HHS launched the National Organ and Tissue
Donation Initiative to increase overall organ and tissue donation. One
aspect of the initiative is to learn more about the factors that
influence organ and tissue donation, with a special emphasis on certain
racial and ethnic communities. Health care workers, particularly in the
area of transplantation, need to understand the various obstacles to
organ donation and transplantation, especially in the groups with which
they work, and to initiate programs and policies that are culturally
sensitive and meaningful.

4-7. Reduce kidney failure due to diabetes.

**Target:** 78 diabetic persons with new cases of ESRD per million
population.

**Baseline:** 113 diabetic persons with new cases of ESRD per million
population were reported in 1996.

**Target setting method:** Better than the best.

**Data source:** U.S. Renal Data System (USRDS), NIH, NIDDK.

Note: The table below may continue to the following page.

+------------------------------------------------+---------------------+
| **Persons With Diabetes, 1996**                | **New Cases of      |
|                                                | ESRD**              |
+================================================+=====================+
|                                                | Rate per Million    |
+------------------------------------------------+---------------------+
| > **TOTAL**                                    | 113                 |
+------------------------------------------------+---------------------+
| **Race and ethnicity**                         |                     |
+------------------------------------------------+---------------------+
| > American Indian or Alaska Native             | 482                 |
+------------------------------------------------+---------------------+
| > Asian or Pacific Islander                    | 156                 |
+------------------------------------------------+---------------------+
| > Asian                                        | DNC                 |
+------------------------------------------------+---------------------+
| > Native Hawaiian and other Pacific Islander   | DNC                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | 329                 |
+------------------------------------------------+---------------------+
| > White                                        | 79                  |
+------------------------------------------------+---------------------+
|                                                |                     |
+------------------------------------------------+---------------------+
| > Hispanic or Latino                           | DNA                 |
+------------------------------------------------+---------------------+
| > Not Hispanic or Latino                       | DNA                 |
+------------------------------------------------+---------------------+
| > Black or African American                    | DNA                 |
+------------------------------------------------+---------------------+
| > White                                        | DNA                 |
+------------------------------------------------+---------------------+
| ###### Gender                                  |                     |
+------------------------------------------------+---------------------+
| > Female                                       | 103                 |
+------------------------------------------------+---------------------+
| > Male                                         | 112                 |
+------------------------------------------------+---------------------+
| **Family income level**                        |                     |
+------------------------------------------------+---------------------+
| > Poor                                         | DNC                 |
+------------------------------------------------+---------------------+
| > Near poor                                    | DNC                 |
+------------------------------------------------+---------------------+
| > Middle/high income                           | DNC                 |
+------------------------------------------------+---------------------+
| ###### Select populations                      |                     |
+------------------------------------------------+---------------------+
| Age groups                                     |                     |
+------------------------------------------------+---------------------+
| > Under 20 years                               | 0                   |
+------------------------------------------------+---------------------+
| > 20 to 44 years                               | 35                  |
+------------------------------------------------+---------------------+
| > 45 to 64 years                               | 276                 |
+------------------------------------------------+---------------------+
| > 65 to 74 years                               | 514                 |
+------------------------------------------------+---------------------+
| > 75 years and older                           | 263                 |
+------------------------------------------------+---------------------+

DNA = Data have not been analyzed. DNC = Data are not collected. DSU =
Data are statistically unreliable.

Note: The table above may have continued from the previous page.

Convincing, consistent, and continuing scientific evidence shows that
with secondary and tertiary prevention, microvascular complications of
diabetes, especially diabetic kidney disease, can be reduced
substantially. Enhanced quality of life, reductions in death rates, and
reduced costs can result from improved clinical and public health
diabetes prevention strategies directed at kidney disease and other
microvascular and metabolic complications of diabetes. Monitoring the
consequences of these strategies, including reductions in the magnitude
of chronic renal insufficiency, terminal kidney failure, and other
microvascular complications, should be an important component of an
effective national public health program.

4-8. (Developmental) Increase the proportion of persons with type 1 or
type 2 diabetes and proteinuria who receive\
recommended medical therapy to reduce progression to chronic renal
insufficiency.

**Potential data sources:** National Ambulatory Medical Care Survey
(NAMCS), CDC, NCHS; National Hospital Ambulatory Medical Care Survey
(NHAMCS), CDC, NCHS.

## Related Objectives From Other Focus Areas

1\. Access to Quality Health Services

1-2. Health insurance coverage for clinical preventive services

1-3. Counseling about health behaviors

1-7. Core competencies in health provider training

5\. Diabetes

5-2. New cases of diabetes

5-3. Overall cases of diagnosed diabetes

5-4. Diagnosis of diabetes

5-7. Cardiovascular disease deaths in persons with diabetes

5-11. Annual urinary microalbumin measurement

5-12. Annual glycosylated hemoglobin measurement

6\. Disability and Secondary Conditions

6-1. Standard definition of people with disabilities in data sets

6-2. Feelings and depression among children with disabilities

6-3. Feelings and depression interfering with activities among adults
with\
disabilities

6-5. Sufficient emotional support among adults with disabilities

6-6. Satisfaction with life among adults with disabilities

6-8. Employment parity

7\. Educational and Community-Based Programs

7-7. Patient and family education

7-8. Satisfaction with patient education

7-9. Health care organization sponsorship of community health promotion\
activities

7-10. Community health promotion programs

7-11. Culturally appropriate and linguistically competent community
health\
promotion programs

8\. Environmental Health

8-11. Elevated blood lead levels in children

8-14. Toxic pollutants

8-20. School policies to protect against environmental hazards

8-22. Lead-based paint testing

8-25. Exposure to heavy metals and other toxic chemicals

8-26. Information systems used for environmental health

8-27. Monitoring environmentally related diseases

8-29. Global burden of disease

10\. Food Safety

10-1. Foodborne infections

10-2. Outbreaks of foodborne infections

10-5. Consumer food safety practices

10-6 Safe food preparation practices in retail establishments

11\. Health Communication

11-2. Health literacy

11-4. Quality of Internet health information sources

11-6. Satisfaction with health care providers' communication skills

12\. Heart Disease and Stroke

12-1. Coronary heart disease (CHD) deaths

12-2. Knowledge of symptoms of heart attack and importance of calling
911

12-6. Heart failure hospitalizations

12-8. Knowledge of early warning symptoms of stroke

12-9. High blood pressure

12-10. High blood pressure control

12-11. Action to help control blood pressure

12-12. Blood pressure monitoring

12-16. LDL-cholesterol level in CHD patients

13\. HIV

13-1. New AIDS cases

13-3. AIDS among persons who inject drugs

13-5. New HIV cases

13-8. HIV counseling and education for persons in substance abuse
treatment

13-12. Screening for STDs and immunization for hepatitis B

13-17. Perinatally acquired HIV infection

14\. Immunization and Infectious Diseases

14-1. Vaccine-preventable diseases

14-2. Hepatitis B in infants and young children

14-3. Hepatitis B in adults and high-risk groups

14-9. Hepatitis C

14-10. Identification of persons with chronic hepatitis C

14-16. Invasive early onset group B streptococcal disease

14-28. Hepatitis B vaccination among high-risk groups

16\. Maternal, Infant, and Child Health

16-10. Low birth weight and very low birth weight

17\. Medical Product Safety

17-1. Monitoring of adverse medical events

17-2. Linked, automated information systems

17-3. Provider review of medications taken by patients

17-6. Blood donations

19\. Nutrition and Overweight

19-1. Healthy weight in adults

19-2. Obesity in adults

19-8. Saturated fat intake

19-17. Nutrition counseling for medical conditions

20\. Occupational Safety and Health

20-7. Elevated blood lead levels from work exposure

22\. Physical Activity and Fitness

22-2. Moderate physical activity

22-3. Vigorous physical activity

22-13. Worksite physical activity and fitness

23\. Public Health Infrastructure

23-2. Public access to information and surveillance data

23-3. Use of geocoding in health data systems

23-4. Data for all population groups

23-5. Data for Leading Health Indicators, Health Status Indicators, and
Priority\
Data Needs at State, Tribal, and local levels

23-6. National tracking of Healthy People 2010 objectives

23-7. Timely release of data on objectives

23-17. Population-based prevention research

25\. Sexually Transmitted Diseases

25-3. Primary and secondary syphilis

25-8. Heterosexually transmitted HIV infection in women

25-10. Neonatal STDs

25-13. Hepatitis B vaccine services in STD clinics

27\. Tobacco Use

27-1. Adult tobacco use

27-2. Adolescent tobacco use

27-5. Smoking cessation by adults

27-7. Smoking cessation by adolescents

27-10. Exposure to environmental tobacco smoke

## Terminology

(A listing of abbreviations and acronyms used in this publication
appears in Appendix H.)

**Arteriovenous fistula:** The type of vascular access created by
joining a person's own (endogenous) artery to the nearby vein. The
increase in blood flow in the vein leads to marked dilation of the vein
and permits an easier insertion of needles for dialysis.

**Chronic renal insufficiency, chronic renal failure, and end‑stage
renal disease (ESRD) (defined in this chapter as treated chronic kidney
failure):** Terms describing the continuum of increasing renal
dysfunction and decreasing glomerular filtration rate (GFR). Because of
the progressive nature of kidney disease, these terms represent
successive stages of disease in most patients.

> **Chronic renal insufficiency:** The stage in chronic kidney disease
> in which damage to the kidney already has resulted in significant
> impairment of renal function, but systemic manifestations are minimal.
> Most patients who have chronic renal insufficiency are asymptomatic.
> Chronic renal insufficiency usually is identified because the serum
> creatinine is slightly elevated (greater than 1.5 mg/dL in males or
> 1.2 mg/dL in females and greater than age‑specific normative values in
> children). The serum creatinine test is insensitive and does not
> identify all persons who have chronic renal insufficiency. Although
> precise GFR limits cannot be assigned to this stage of disease,
> typically patients with chronic renal insufficiency have a GFR between
> 30 ml/min and 75 ml/min.
>
> **Chronic renal failure:** The stage in chronic renal disease in which
> renal dysfunction has progressed to a level resulting in systemic
> manifestations. These manifestations include a rise in the blood
> concentration of urea, creatinine, and phosphate, which are removed by
> the kidneys, and other problems, such as anemia, bone disease,
> acidosis, and salt and fluid retention. Growth failure may be seen in
> children. Most patients with chronic renal failure progress to treated
> chronic kidney failure (end‑stage renal disease).
>
> **End‑stage renal disease (ESRD) (referred to in this focus area as
> treated chronic kidney failure):** The stage in chronic renal disease
> in which renal replacement therapy, dialysis, or kidney
> transplantation is needed to sustain life. Treated chronic kidney
> failure is generally an irreversible state. The glomerular filtration
> rate is usually less than 10 ml/min.

**Diabetes (diabetes mellitus):** A chronic disease due to insulin
deficiency or resistance to insulin action and associated with
hyperglycemia (elevated blood glucose levels). Over time, without proper
preventive treatment, organ complications related to diabetes develop,
including heart, nerve, foot, eye, and kidney damage as well as problems
with pregnancy. Diabetes is classified into two major categories.

**Type 1 diabetes (previously called insulin-dependent diabetes mellitus
\[IDDM\] or juvenile‑onset diabetes \[JODM\]):** Represents clinically
about 5 percent of all persons with diagnosed diabetes. Its clinical
onset typically occurs at ages under 30 years, with more gradual
development after age 30. Most often type 1 diabetes represents an
autoimmune destructive disease in the beta (insulin‑producing) cells of
the pancreas in genetically susceptible individuals. Insulin therapy
always is required to sustain life and maintain diabetes control.

**Type 2 diabetes (previously called noninsulin‑dependent diabetes
mellitus \[NIDDM\] or adult‑onset diabetes \[AODM\]):** Refers to the
most common form of diabetes in the United States and the world,
especially in certain racial and ethnic groups and in elderly persons.
Women who develop diabetes during pregnancy also are at increased risk
of developing this type of diabetes later in life. In the United States,
approximately 95 percent of all persons with diagnosed diabetes (10.5
million) and 100 percent of all persons with undiagnosed (5.5 million)
diabetes probably have type 2 diabetes.

**Diabetic kidney disease:** Kidney disease and resultant kidney
functional impairment due to the longstanding effects of diabetes on the
microvasculature of the kidney. Features include increased urine protein
and decreased kidney function.

**Dialysis:** The process by which metabolic waste products are removed
by cleansing of the blood directly through extracorporeal filtration
membranes (hemodialysis) or indirectly by diffusion of waste products
through the peritoneal membranes into instilled fluids (peritoneal
dialysis).

**End‑stage renal disease:** See above.

**Glomerular filtration:** The process by which the kidneys filter the
blood, clearing it of toxins.

**Glomerular filtration rate (GFR):** The rate at which the blood is
cleared by glomerular filtration and an important measure of kidney
function. Normal GFR values in adults are between 100 and 150 ml/min.
One of the most important hallmarks of chronic renal disease is a
progressive decline in the rate of glomerular filtration. Generally, a
GFR below 75 ml/min represents clinically significant renal
insufficiency. A GFR of less than 10 ml/min represents kidney failure
severe enough to require renal replacement therapy to maintain life.

**Hemodialysis:** The process by which biologic waste products are
removed from the body through external blood circuit and external
(artificial) membranes.

**Glomerulonephritis:** Inflammation in the primary filtration units
(glomeruli) of the kidneys. Typically, this process leads to loss of
blood, blood products, and protein into the urine. Unchecked or without
effective treatment, this process could lead ultimately to permanent
kidney damage and loss of kidney function and chronic kidney failure.

**Incidence rate:** A measure of the number of new cases of disease
occurring in a specific population over a specific period of time,
usually 1 year. For end‑stage renal disease, the best information is
based on the incidence of treated end‑stage kidney disease reported
through Medicare to the U.S. Renal Data System. Available data exclude
those patients who die without receiving treatment.

**Interstitial nephritis:** Inflammation in the supporting matrix of the
kidneys. This process could result from damage caused by microorganisms
(such as bacteria and viruses) or from toxic reaction to drugs or other
substances such as lead and mercury.

**Microalbuminuria:** Abnormally elevated levels of albumin in the
urine---but at levels too low to be detectable by the dipstick method
used to test for protein in the urine. Increased urinary excretion of
albumin, even if the concentration is too low to be detectable as
dipstick proteinuria, has been associated with increased risk of
progressive kidney disease in people with diabetes**^6,\ 7^** and
increased risk of subsequent death in persons with**^8^** and without
diabetes**^9,\ 10^** and in elderly individuals.**^11^**
Microalbuminuria can be measured in several ways. If a random urine
sample is used, the albumin concentration in the first‑voided morning
urine or the ratio of urine albumin to urine creatinine can be used. If
a timed urine collection is available, an albumin excretion rate can be
determined. Urine albumin concentrations of 30 to 300 μg/ml, urinary
albumin to creatinine ratios of less than 3.5 mg/mmol, and urine albumin
excretion rates of less than 15 μg/min all have been used as cutoff
values for detection of microalbuminuria.

**Patient year (at risk):** A measure of the duration (in years) a
patient has been exposed to the effects of a particular biologic or
physiologic condition, such as chronic renal insufficiency or the
effects of dialysis.

**Polycystic kidney disease:** A disorder (usually inherited) of the
kidneys in which the normal kidney structures (particularly, the
tubules) are replaced by sacs (or cysts) that ultimately increase in
size and lead to further destruction of the supporting matrix of the
kidneys. The most common variety is the adult polycystic kidney disease
(ADPKD), which is inherited as an autosomal dominant genetic disease.
ADPKD is usually characterized by elevated blood pressure, pain from
enlarged cysts, blood in the urine, and a relentless progression to
terminal kidney failure.

**Prevalence rate:** A measure of the total number of cases of disease
existing in a specific population at a certain point in time (point
prevalence) or over a certain period of time (period prevalence).
Point-prevalence rates reflect the number of individuals at the stated
date.

**Proteinuria:** Abnormal levels of protein in the urine. Proteinuria is
a marker for structural kidney damage or inflammation and also may be
involved in the pathogenesis of progressive renal injury. Increased
risks of developing progressive renal disease,**^1,\ 2^** of
death,**^3,\ 4^** and of death due to cardiovascular disease**^5^** have
been documented in persons with persistent proteinuria. Urine protein
can be estimated by a dipstick method, which provides a semiquantitative
estimate of concentration. More accurate measures include determining
the ratio of urine protein to urine creatinine or the amount of protein
excreted by a person in a 24-hour period.

**Renal disease:** A synonym for kidney disease.

**Serum creatinine:** A blood chemistry measurement used to estimate the
level of kidney function. Serum creatinine is an important index for
monitoring progression of disease in persons with chronic renal disease.
Elevations in serum creatinine are an insensitive marker of early
chronic renal insufficiency. In advanced renal failure, however, a
change in serum creatinine is a more reliable indicator. This test
remains the most widely available method used to estimate the glomerular
filtration rate or to monitor changes in level of renal
function.**^12^**

**U.S. Renal Data System (USRDS):** A national database of information
on treated chronic kidney failure patients---new cases, illness,
disability, and death outcomes. USRDS is based predominantly on data
collected by the Health Care Financing Administration's Medicare treated
chronic kidney failure program and is funded by a contract from the
National Institutes of Health.**^13^** This database contains
information on approximately 93 percent of all patients treated for
treated chronic kidney failure in the United States. Most of the data
cited in this focus area derive from USRDS reports. As noted, these
numbers reflect reported cases of treated end-stage renal disease and,
therefore, do not include patients who die without treatment or patients
whose care is not reported to USRDS.

**Vascular access:** The means by which blood is removed from a person
for cleansing during dialysis and safely and easily returned, when
cleaned, into the body.

**Vasculitis:** Inflammation of the blood vessels. Typically, the cause
of this process is unknown. Untreated, it leads to progression to
relentless and specific organ failures, including chronic kidney
failure, or death.

## References

[^1]: Jones, C.A.; McQuillan, G.M.; Kusek, J.W.; et al. Serum creatinine
    levels in the U.S. population: Third National Health and Nutrition
    Examination Survey. *American Journal of Kidney Diseases*
    32:992‑999, 1998.

[^2]: U.S. Renal Data System (USRDS). *1999 Annual Data Report (ADR).*
    Bethesda, MD: National Institutes of Health (NIH), National
    Institute of Diabetes and Digestive and Kidney Diseases (NIDDK),
    April 1999, Appendix, Table A‑1.

[^3]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Appendix,
    Tables A‑1 and B‑3.

[^4]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Chapter
    X, 133‑148.

[^5]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Chapter
    V, 63‑78.

[^6]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Appendix,
    Table A‑1.

[^7]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Appendix,
    Table A‑15.

[^8]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Appendix,
    Table A‑3.

[^9]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Appendix,
    Table A‑1.

[^10]: National Heart, Lung, and Blood Institute. *Morbidity and
    Mortality Chartbook on Cardiovascular Disease, Lung and Blood
    Diseases.* Bethesda, MD: Public Health Service, 1998.

[^11]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Tables A‑1, A‑2, and A‑3.

[^12]: Clark, C. How should we respond to the worldwide diabetes
    epidemic? *Diabetes Care* 21:475‑476, 1998.

[^13]: Centers for Disease Control and Prevention (CDC). *National
    Diabetes Fact Sheet: National Estimates and General Information on
    Diabetes in the United States.* Atlanta, GA: U.S. Department of
    Health and Human Services, 1997.

[^14]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Table A‑6.

[^15]: Eggers, P.W. Personal communication. Health Care Financing
    Administration. 1999.

[^16]: Perneger, T.V.; Klag, M.J.; Feldman, H.I.; et al. Projection of
    hypertension related renal disease in middle‑aged residents of the
    United States. *Journal of the American Medical Association*
    269(10):1272‑1277, 1993.

[^17]: Whittle, J.C.; Whelton, P.K.; Seidler, A.J.; et al. Does racial
    variation in risk factors explain black-white differences in the
    incidence of hypertensive end‑stage renal disease? *Archives of
    Internal Medicine* 151:1359‑1364, 1991.

[^18]: Brancati, F.L.; Whittle, J.C.; Whelton, P.K.; et al. The excess
    incidence of diabetic end-stage renal disease among blacks. A
    population based study of potential explanatory factors. *Journal of
    the American Medical Association* 268:3079‑3084, 1992.

[^19]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Tables A‑1 and A‑14.

[^20]: Gonzales Villalpano, C.G.; Stern, M.P.; Arrendondo Perez, B.; et
    al. Nephropathy in low income diabetics: The Mexico City Diabetes
    Study. *Archives of Medical Research* 27:367‑372, 1996.

[^21]: Pugh, J.A.; Stern, M.P.; Haffner, S.M.; et al. Excess incidence
    of treatment of end‑stage renal disease in Mexican Americans.
    *American Journal of Epidemiology* 127:135‑144, 1998.

[^22]: Agodoa, L.Y.C.; Roys, E.C.; Wolfe, R.A.; et al. ESRD among
    Hispanics in the U.S. *Journal of the American Society of
    Nephrology* 10:232A, 1999.

[^23]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Table B‑3.

[^24]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Table ES‑1.

[^25]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Table A-6.

[^26]: Rettig, R., and Levinsky, N.G. *Kidney Failure and the Federal
    Government.* Washington, DC: National Academy Press, 1991.

[^27]: Port, F.K.; Wolfe, B.A.; Mauger, E.A.; et al. Comparison of
    survival probabilities for dialysis patients vs. cadaveric renal
    transplant recipients. *Journal of the American Medical Association*
    270(11):1339-1343, 1993.

[^28]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Table F-1.

[^29]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, Chapter
    VII, 104-106.

[^30]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999,
    Appendix, Table F-2.

[^31]: Freedman, B.I.; Tuttle, A.B.; and Spray, B.J. Familial
    predisposition to nephropathy in African Americans with
    non-insulin-dependent diabetes mellitus. *Kidney Diseases*
    25(5):710-713, 1995.

[^32]: Siegel, J.; Krolewski, A.; Warran, J.; et al. Cost-effectiveness
    of screening and early treatment of nephropathy in patients with
    insulin-dependent diabetes mellitus. *Journal of the American
    Society of Nephrology* 3:S111‑S119, 1992.

[^33]: Kiberd, B., and Jindal, K. Screening to prevent renal failure in
    insulin dependent diabetic patients: An economic evaluation.
    *British Medical Journal* 311:1595‑1599, 1995.

[^34]: Borch-Johnsen, K.; Wenzel, H.; Viberti, G.; et al. Is screening
    and intervention for microalbuminuria worthwhile in patients with
    insulin dependent diabetes? *British Medical Journal* 306:1722‑1725,
    1993.

[^35]: Ifudu, O.; Dawood, M.; Homel, P.; et al. Excess morbidity in
    patients starting uremia therapy without prior care by a
    nephrologist. *American Journal of Kidney Diseases* 28:841-845,
    1996.

[^36]: USRDS. *1997 ADR.* Bethesda, MD: NIH, NIDDK, April 1997, 49-60.

[^37]: USRDS. *1998 ADR.* Bethesda, MD: NIH, NIDDK, April 1998, Table
    G-19.

[^38]: USRDS. *1998 ADR.* Bethesda, MD: NIH, NIDDK, April 1998,
    Appendix, Table G-43.

[^39]: Turenne, M.N.; Port, F.K.; Strawderman, R.L.; et al. Growth rates
    in pediatric dialysis patients and renal transplant recipients.
    *American Journal of Kidney Diseases* 30(2):193‑203, 1997.

[^40]: United Network for Organ Sharing (UNOS). *1997 Report of the
    Organ Procurement and Transplantation Network: Waiting List Activity
    and Donor Procurement.* Executive Summary, Kidney Volume. Richmond,
    VA: UNOS, 1997.

[^41]: Alexander, G.C., and Sehgal, A.R. Barriers to cadaveric renal
    transplantation among blacks, women, and the poor. *Journal of the
    American Medical Association* 280(13):1148‑1152, 1998.

[^42]: Bloembergen, W.E.; Mauger, E.A.; and Wolfe, R.A. Association of
    gender and access to cadaveric renal transplantation. *American
    Journal of Kidney Diseases* 30(6):733‑738, 1997.

[^43]: Narva, A.; Stiles, S.; Karp, S.; et al. Access of Native
    Americans to renal transplantation in Arizona and New Mexico. *Blood
    Purification* 14:293‑304, 1996.

[^44]: Ozminkowski, R.J.; White, A.J.; Hassol, A.; et al. Minimizing
    racial disparity regarding receipt of a cadaver kidney transplant.
    *American Journal of Kidney Diseases* 30:749‑759, 1997.

[^45]: USRDS. *1997 ADR.* Bethesda, MD: NIH, NIDDK, April 1997, 107‑112.

[^46]: Levey, A.S.; Beto, J.A.; Coronado, B.E.; et al. Controlling the
    epidemic of cardiovascular disease in chronic renal disease. What do
    we know? What do we need to learn? Where do we go from here? *Report
    of the National Kidney Foundation Task Force on Cardiovascular
    Disease.* New York, NY: National Kidney Foundation, July 1998.

[^47]: Bostom, A.G.; Shemin, D.; Verhoef, P.; et al. Elevated fasting
    total plasma homocysteine levels and cardiovascular disease outcomes
    in maintenance dialysis patients: A prospective study.
    *Arteriosclerosis, Thrombosis, and Vascular Biology*
    17(11):2554‑2558, 1997.

[^48]: Bostom, A.G., and Lathrop, L. Hyperhomocysteinemia in end‑stage
    renal disease: Prevalence, etiology, and potential relationship to
    arteriosclerotic outcomes. *Kidney International* 52(1):10‑20, 1997.

[^49]: Bostom, A.G.; Shemin, D.; Lapane, K.L.; et al.
    Hyperhomocysteinemia, hyperfibrinogenemia, and lipoprotein (a)
    excess in maintenance dialysis patients: A matched case-control
    study. *Arteriosclerosis* 125(1):91‑101, 1996.

[^50]: Perneger, T.V.; Klag, M.J.; and Whelton, P.K. Cause of death in
    patients with end‑stage renal disease: Death certificates vs.
    registry reports. *American Journal of Public Health*
    83(12):1735-1738, 1993.

[^51]: USRDS. *1997 ADR.* Bethesda, MD: NIH, NIDDK, April 1997, Figure
    IV-3, 52.

[^52]: National Kidney Foundation. *Dialysis Outcomes, Quality
    Initiatives, Clinical Practice Guidelines.* Executive Summaries. New
    York, NY: the Foundation, 1997.

[^53]: USRDS. *1999 ADR.* Bethesda, MD: NIH, NIDDK, April 1999, 159.

[^54]: Hirth, R.A.; Turenne, M.N.; Woods, J.D.; et al. Vascular access
    in newly treated U.S. hemodialysis patients: Predictors and trends.
    *Journal of the American Medical Association* 276:1303‑1308, 1996.

[^55]: Soucie, J.M.; Neylan, J.F.; and McClellan, W. Race and sex
    differences in the identification of candidates for renal
    transplantation. *American Journal of Kidney Diseases* 19:414‑419,
    1992.

[^56]: Kasiske, B.L.; London, W.; and Ellison, M.D. Race and
    socioeconomic factors influencing early placement on the kidney
    transplant waiting list. *Journal of the American Society of
    Nephrology* 9:2142‑2147, 1998.

[^57]: Ellison, M.D.; Breen, T.J.; Guo, T.G.; et al. Blacks and whites
    on the UNOS renal waiting list: Waiting times and patient
    demographics compared. *Transplantation Proceedings*
    25(4):2462‑2466, 1993.

[^58]: Thompson, J.S. American Society of Histocompatibility and
    Immunogenetics CrossMatch Study. *Transplantation* 59(11):1636‑1638,
    1995.

[^59]: Sanfilippo, F.P.; Vaughn, W.K.; Peters, T.G.; et al. Factors
    affecting the waiting time of cadaveric kidney transplant candidates
    in the United States. *Journal of the American Medical Association*
    267:247‑252, 1992.

[^60]: McCauley, J.; Irish, W.; Thompson, L.; et al. Factors determining
    the rate of referral, transplantation, and survival on dialysis in
    women with ESRD. *American Journal of Kidney Diseases* 30:739‑748,
    1997.