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org EDITORIALS
Growth of the ESKD Population:
Progress or Peril?
Allan J. Collins
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School of Medicine, University of Minnesota, Minneapolis, Minnesota
J Am Soc Nephrol 30: 3–4, 2019.
doi: https://doi.org/10.1681/ASN.2018111135
nYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdgGj2MwlZLeI= on 05/03/2023
Since 1973, when Congress created entitlement for treatment
under the Medicare system, growth in the dialysis and kidney
transplant population has been remarkable. In 2016, this pop-
ulation totaled .726,000 patients—511,000 on dialysis and
215,000 with a kidney transplant1; this is .18 times the initial
expectation of 40,000 individuals. This number continues to
rise.
This remarkable growth in the ESRD population arises
from a number of factors: improved survival of the general
population secondary to pharmacologic advances; increased
access to dialysis; advances in dialysis, such as bicarbonate
dialysate and synthetic membranes; improvements in prescrib-
ing appropriate treatments; home-based dialysis; quality im-
provement programs addressing vascular access; and improved
immunosuppressive therapy for patients with kidney
transplants.
Projecting the number of patients with ESRD using various
assumptions about the determinants of growth in this popu-
lation has been a perennial research effort intended to inform
policy makers, insurers, and providers about the future patient
population. In this issue of the Journal of the American Society
of Nephrology, McCullough et al.2 developed projections to
2030—the longest projection to date—using a population-
based transitional model and examining changes in incident
rates that could unfold, taking into account obesity and di-
abetes rates and the aging of the general population in the
United States. On the basis of these assumptions, their pre-
dicted range for the ESRD population is 971,000–1,259,000.
Projections, of course, cannot simply look at new patients,
because death rates have a substantial effect over time. Along
with obvious new patients, the prevalent population comprises
patients who have had an episode of AKI, recover kidney func-
tion, and return to ESRD treatment; patients who switch
between dialysis modalities; and patients with kidney
transplants—a modality with markedly higher survival com-
pared with dialysis. Increase in the kidney transplant popula-
tion is limited by access to available organs; this can change
Published online ahead of print. Publication date available at www.jasn.org.
Correspondence: Dr. Allan J. Collins, US Renal Data System, Minneapolis
Medical Research Foundation, 701 Park Avenue, Suite S4.100, Minneapolis,
MN 55415. Email: acollinswhitepine@gmail.com
Copyright © 2019 by the American Society of Nephrology
J Am Soc Nephrol 30: 1–6, 2019
over time as seen with the recent increase in available organs
resulting from opiate overdoses, leading to higher transplanta-
tion rates.3 Relatively healthy patients with ESRD on the wait-
ing list for a transplant accumulate on dialysis, which leads to
lower overall death rates.
Growth in the ESRD population has not been accompanied
by a comparable growth in the number of organs available for
transplant. Between 2004 and 2014, the number of kidney
transplants increased only 5% from 17,148 to 17,998.4 The
waitlisted population, however, grew 61% from 53,419 to
86,064, adding 32,645 patients to the prevalent dialysis pop-
ulation in 2014—an increase of 7%.3 Accounting for such
issues is a challenge when making projections.
The authors hypothesized that obesity and diabetes would
be major drivers of future growth in the ESRD population.
However, the effect of death rates among existing patients on
dialysis and patients with transplants on the overall growth of
the prevalent ESRD population is four to five times the effect
from changes in the incidence rate, insofar as obesity influences
incidence. Although preventing the progression of CKD to
ESRD is an important public health objective, it is often not
apparent in the shorter term how such efforts might affect
growth in the dialysis and transplant populations. For example,
the competing effects on cardiovascular and renal outcomes of
two classes of diabetes drugs, glucagon-like peptide-1 receptor
agonists and sodium-glucose cotransporter 2 inhibitors, will
take time to manifest in the general population.
Access to kidney transplantation is a core issue, with trans-
plant providing the best outcome at the most reasonable cost
to the health care system. After transplant, drivers of mor-
tality need greater consideration. Remarkable progress has
been made in reducing the death rates; Wetmore et al.5 show a
drop of almost 28% between 2000 and 2013, in parallel
with a decline in mortality from cardiovascular disease and
cancer in the general population.6 The recent flattening of
the death rates in the ESRD population in the United States
—particularly in the dialysis population—is a major con-
cern.7 Assuming that rates remain flat, McCullough et al.2
project an ESRD population of 971,000 by 2030; this is a 34%
increase from the 2016 total of 726,331 or 2.1% per year, an
annual increase that would be the lowest in over two
decades.8
The real test of any projection is how close it comes to
actual data. This is where reality meets academic exercise.
Two prior projections by Xue et al.9 and Gilbertson et al.10
were within 10% of the projected prevalent population. Xue
et al.9 used a simplified autoregression technique with var-
ious smoothing techniques, an approach that simply as-
sumes that historical patterns of growth and death rates
will continue. Their projection of the incident population
was markedly off, primarily because the approach did not
consider a slowing of the historical rates; their projection of
the prevalent population, however, was close to what tran-
spired. Gilbertson et al.10 used a more detailed nonstation-
ary Markov chain model, projecting 10-year trends in
Editorials 3
 EDITORIALS www.jasn.org
mortality and incidence on the basis of the most recent
year’s data. This approach also overestimated the incident
population but was within 10% for the prevalent popula-
tion, erring on the high side by assuming falling death rates
in the dialysis population.
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The lower end of the projection by McCullough et al.2 may
be too conservative, because the incident 90-day death rates
given in the US Renal Data System 2018 Annual Data Report
show a decline.11 As noted above, the upper end projection of
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1,259,000 does not consider the effect of the two basic modal-
ities of kidney transplantation and dialysis. Because the
authors did not use an integrated approach to project these
populations, it is difficult to assess the inter-related issues of
access to organs—which drives growth in the transplant pop-
ulation and removes healthy patients from the dialysis pool—
and changing death rates in the prevalent dialysis population.
It is important to acknowledge the inevitable uncertainties
in 15-year projections. Ongoing efforts to prevent kidney dis-
ease and slow its progression may start to have an effect.
Changes in organ availability and death rates will certainly
have an important influence. Future models should build
in a range of estimates of these possible changes. This would
allow for greater clarity of the realities facing patients and
providers today.
DISCLOSURES
A.J.C. served as Director of the US Renal Data System from 1999 to 2014
when the prior two projections were published. A.J.C. is currently the Chief
Medical Officer of NxStage Medical, Inc., a home hemodialysis and acute
dialysis product company.
REFERENCES
1. US Renal Data System: Reference tables D.6 and D.9. In: 2018 USRDS
Annual Data Report: Epidemiology of Kidney Disease in the United
States, Bethesda, MD, National Institutes of Health, National In-
stitute of Diabetes and Digestive and Kidney Diseases, 2018. Avail-
able at: https://www.usrds.org/reference.aspx. Accessed October 25,
2018
2. McCullough KP, Morgenstern H, Saran R, Herman WH, Robinson BM:
Projecting ESRD incidence and prevalence in the United States
through 2030. J Am Soc Nephrol 30: 127–135, 2019
3. Mehra MR, Jarcho JA, Cherikh W, Vaduganathan M, Lehman RR,
Smits J, et al.: The drug-intoxication epidemic and solid-organ
transplantation. N Engl J Med 378: 1943–1945, 2018
4. US Renal Data System: Reference tables E.3 and E.6. In: 2018 USRDS
Annual Data Report: Epidemiology of Kidney Disease in the United
States, Bethesda, MD, National Institutes of Health, National Institute
of Diabetes and Digestive and Kidney Diseases, 2018. Available at:
https://www.usrds.org/reference.aspx. Accessed October 25, 2018
5. Wetmore JB, Liu J, Li S, Hu Y, Peng Y, Gilbertson DT, et al.: The Healthy
People 2020 objectives for kidney disease: How far have we come, and
where do we need to go? Clin J Am Soc Nephrol 12: 200–209, 2017
6. NCD Countdown 2030 collaborators: NCD Countdown 2030: World-
wide trends in non-communicable disease mortality and progress
towards Sustainable Development Goal target 3.4. Lancet 392: 1072–
1088, 2018
7. US Renal Data System: Reference table H.4. In: 2018 USRDS Annual
Data Report: Epidemiology of Kidney Disease in the United States,
4 Journal of the American Society of Nephrology
Bethesda, MD, National Institutes of Health, National Institute of Di-
abetes and Digestive and Kidney Diseases, 2018. Available at: https://
www.usrds.org/reference.aspx. Accessed October 25, 2018
8. US Renal Data System: Reference table D.6. In: 2018 USRDS Annual
Data Report: Epidemiology of Kidney Disease in the United States,
Bethesda, MD, National Institutes of Health, National Institute of Di-
abetes and Digestive and Kidney Diseases, 2018. Available at: https://
www.usrds.org/reference.aspx. Accessed October 25, 2018
9. Xue JL, Ma JZ, Louis TA, Collins AJ: Forecast of the number of patients
with end-stage renal disease in the United States to the year 2010. J Am
Soc Nephrol 12: 2753–2758, 2001
10. Gilbertson DT, Liu J, Xue JL, Louis TA, Solid CA, Ebben JP, et al.:
Projecting the number of patients with end-stage renal disease in the
United States to the year 2015. J Am Soc Nephrol 16: 3736–3741, 2005
11. US Renal Data System: Healthy people 2020. In: 2018 USRDS Annual Data
Report: Epidemiology of Kidney Disease in the United States, Bethesda,
MD, National Institutes of Health, National Institute of Diabetes and Di-
gestive and Kidney Diseases, 2018. Available at: https://www.usrds.org/
2018/view/Default.aspx. Accessed October 25, 2018
See related article, “Projecting ESRD Incidence and Prevalence in the United
States through 2030,” on pages 127–135.
Postoperative AKI—Prevention
Is Better than Cure?
Samira Bell1,2 and John Prowle3,4
1
Renal Unit, Ninewells Hospital, Dundee, United Kingdom; 2Division
of Population Health Science and Genomics, School of Medicine,
University of Dundee, Dundee, United Kingdom; 3Adult Critical Care
Unit and Department of Renal Medicine and Transplantation, The
Royal London Hospital, Barts Health National Health Service Trust,
London, United Kingdom; and 4William Harvey Research Institute,
Queen Mary University of London, London, United Kingdom
J Am Soc Nephrol 30: 4–6, 2019.
doi: https://doi.org/10.1681/ASN.2018111127
AKI could be considered as a sentinel postoperative compli-
cation, because it is relatively common and strongly associated
with increased short- and long-term risk of death, the devel-
opment of other postoperative complications, increased length
of hospital stay, and potentially, the development of progressive
CKD.1 Consequently, patients with AKI after surgery are an
area of unmet clinical need and a major burden on health care
resources. In the absence of effective interventions to treat
established AKI, preoperative identification of patients at
high risk of AKI allows for perioperative optimization to pre-
vent or reduce the severity of AKI. A number of large
Published online ahead of print. Publication date available at www.jasn.org.
Correspondence: Dr. Samira Bell, Division of Population Health Science and
Genomics, School of Medicine, University of Dundee, Mackenzie Building, Kirsty
Semple Way, Dundee DD2 4BF, United Kingdom. Email: Samira.bell@nhs.net
Copyright © 2019 by the American Society of Nephrology
J Am Soc Nephrol 30: 1–6, 2019