INTRODUCTION — Chronic kidney disease (CKD) is a worldwide public health problem. The number of patients enrolled in the end-stage renal disease (ESRD) Medicare-funded program has increased from approximately 10,000 beneficiaries in 1973 to 703,243 as of 2015 [1,2].
Although the exact reasons for the growth of the ESRD program are unknown, changes in the demographics of the population, differences in disease burden among racial groups, and under-recognition of earlier stages of CKD and of risk factors for CKD may partially explain this growth [3-6].
Patients with ESRD consume a disproportionate share of health care resources.
However, despite the magnitude of the resources committed to the treatment of ESRD and the substantial improvements in the quality of dialysis therapy, these patients continue to experience significant mortality and morbidity and a reduced quality of life.
This topic reviews the epidemiology of CKD and its associated morbidity and mortality. Overviews of the management of CKD, its complications, and screening recommendations are discussed separately. (See "Overview of the management of chronic kidney disease in adults".)
PREVALENCE OF CKD — The Kidney Disease: Improving Global Outcomes (KDIGO) has defined CKD as abnormalities of kidney structure or function present for >3 months with implications for health. Such abnormalities may include one or more markers of kidney damage (eg, albuminuria >30 mg/g of creatinine, urine sediment abnormalities, electrolyte and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, or history of kidney transplantation) or the presence of glomerular filtration rate (GFR) <60 mL/ min/1.73 m2 (GFR categories 3a to 5) [7].
Formulas that utilize easily obtained values have been developed that help estimate the GFR. These include the Modification of Diet in Renal Disease (MDRD) and CKD Epidemiology Collaboration (CKD-EPI) equations. (See "Assessment of kidney function".)
According to the National Health and Nutrition Examination Survey (NHANES) performed in 2011 to 2014, the overall CKD prevalence in the United States adult population was 14.8 percent (95% CI 13.6–16.0). Using a GFR of <60 mL/min/1.73 m2 as a definition for CKD, the prevalence was 7.2 percent (95% CI 6.5-7.2) or 8.3 million.
Based upon these definitions, the following was the recommended classification of CKD by stage and the estimated prevalence within the United States of each stage, as largely determined by the NHANES performed in 2011 to 2014 [3,8-11]:
●Stage 1 disease is defined by a normal GFR (>90 mL/min/1.73 m2) and persistent albuminuria (4.7 percent of the total United States adult population).
●Stage 2 disease is a GFR between 60 to 89 mL/min/1.73 m2 and persistent albuminuria (2.9 percent).
●Stage 3 disease is a GFR between 30 and 59 mL/min/1.73 m2 (6.6 percent).
●Stage 4 disease is a GFR between 15 and 29 mL/min/1.73 m2 (0.4 percent).
●Stage 5 disease is a GFR of <15 mL/min/1.73 m2 or end-stage renal disease (ESRD; 0.2 percent).
Since the original Kidney Disease Outcomes Quality Initiative (KDOQI) classification was published, stage 3 CKD (GFR of 30 to 59 mL/min/1.73 m2) has been subdivided into GFR stages 3a and 3b to more accurately reflect the continuous association between lower GFR and risk for mortality and adverse kidney outcomes (figure 1) [12]. Patients receiving treatment with dialysis are subclassified as GFR stage 5D to highlight the specialized care that they require. (See "Definition and staging of chronic kidney disease in adults", section on 'Staging of CKD'.)
Compared with 1988 to 1994, the overall prevalence of CKD stages 1 to 4 increased significantly in the period from 1999 to 2004 but stabilized in 2011 [8-11]. Data from the NHANES database, with GFR estimated with the CKD-EPI equation, showed that the overall prevalence of CKD stages 3 through 4 increased from 4.8 percent (95% CI 4.3-5.4) in 1988 to 1994 to 6.9 percent (95% CI 5.9-7.9) and remained stable after that with prevalence of 6.9 percent (95% CI 5.5-8.3) in 2011 to 2012 [13]. The prevalence was largely unchanged when the definition of CKD was broadened to include individuals with estimated GFR (eGFR) ≥60 mL/min/1.73 m2 and a one-time demonstration of increased protein excretion (defined by urine albumin to creatinine ratio of >30 mg/g). (See "Assessment of urinary protein excretion and evaluation of isolated non-nephrotic proteinuria in adults", section on 'Quantitative measurement'.)
Given that a decreased GFR is commonly observed in the older adult population, these strict definitions of kidney disease imply that a large percentage of older adults are classified as having kidney disease, despite stable kidney function. This has been shown in a variety of studies. As examples:
●One study from Japan calculated the creatinine clearance using the Cockcroft-Gault method among nearly 100,000 subjects >20 years of age who participated in a mass screening [14]. Based upon these KDOQI definitions, >80 percent of those >70 years of age would be considered to have at least stage 3 disease.
●A population-based cross-sectional study of >6000 healthy men and women in the Netherlands determined that 42 percent of men and 44 percent of women >85 years of age had an MDRD eGFR <60 mL/min/1.73 m2 [15].
Age- and gender-specific eGFR values may provide a more accurate definition of CKD than KDIGO definitions [16]. The CKD-EPI equation may provide more accurate estimates of the GFR, especially among individuals who have normal or only mildly reduced GFR. Analysis of NHANES data with GFR estimated with the CKD-EPI equation showed that, among individuals ages 65 to 79 years, the prevalence of stage 3 and 4 CKD was 21.7 percent (95% CI 18-25.4) in 2011 to 2012 [13]. This is down from prevalence of 25.1 percent (95% CI 20.7-29.5) in 2003 to 2004. (See "Assessment of kidney function".)
Albuminuria — The three albuminuria stages follow familiar definitions of normal, moderately increased (formerly called "microalbuminuria"), and severely increased (formerly called "macroalbuminuria" and nephrotic range) albuminuria (table 1):
●A1 − albumin creatinine ratio (ACR) <30 mg/g (<3.4 mg/mmol)
●A2 − ACR 30 to 300 mg/g (3.4 to 34.0 mg/mmol)
●A3 − ACR >300 mg/g (>34.0 mg/mmol)
The addition of albuminuria staging to GFR staging is new since the original KDOQI classification scheme was published [3,17,18]. Albuminuria staging has been added because of the graded increase in risk for mortality, progression of CKD, and ESRD at higher levels of albuminuria, independent of eGFR, without an apparent threshold value (figure 1 and figure 2) [12]. The increase in risk is significant for urine ACR values ≥30 mg/g, even when GFR is >60 mL/min/1.73 m2, consistent with the current threshold value for albuminuria (≥30 mg/g) as a marker of kidney damage. An increased risk is also apparent with urine ACR levels between 10 and 29 mg/g ("high-normal" albuminuria), suggesting that levels <30 mg/g may also warrant increased attention. (See "Definition and staging of chronic kidney disease in adults", section on 'Albuminuria'.)
Increased urinary protein excretion is the earliest clinical finding of diabetic nephropathy. Moderately increased albuminuria may also be an early marker for nondiabetic CKD and is a risk factor for cardiovascular disease (CVD). In some nondiabetics, for example, moderately increased albuminuria may be a general signal via the kidney that the vasculature in general is not functioning normally. (See "Moderately increased albuminuria (microalbuminuria) and cardiovascular disease".)
An analysis of NHANES data from 4101 individuals in the years 1999 to 2000 evaluated the prevalence of increased albuminuria alone as a marker of early kidney disease [8]. The overall prevalence of severely increased albuminuria (defined as urine albumin concentration >300 mg/g) was 1.3 percent and was higher in males (1.7 percent) than females (0.9 percent). The overall prevalence of moderately increased albuminuria (defined as urinary ACR ≥30 mg/g but <300 mg/g) was 8.8 percent and was lower in males (7.3 percent) than females (10.4 percent), which may be explained by the higher average urine creatinine in men compared with women. As expected, there was a higher prevalence of albuminuria among individuals with diabetes. These values are higher than those observed in the years 1988 to 1994, which held generally for gender, age, and race/ethnicity [19]. However, based on NHANES data, the overall prevalence of moderately and severely increased albuminuria has remained stable between 1999 to 2002 (8.6 and 1.3 percent, respectively) and 2011 to 2014 (8.5 and 1.4 percent, respectively) [20].
The ACR, combined with eGFR, may provide a better predictor of patients at risk for progression to ESRD than eGFR alone. This was shown in an analysis of data from the Nord-Trøndelag Health (HUNT 2) Study [21]. Of 65,589 adults who participated in the study, 124 patients progressed to ESRD after 10 years of follow-up. Both eGFR and albuminuria were independently and strongly associated with progression to ESRD. Combining the albumin/creatinine ratio with the eGFR provided the most discriminating model for predicting progression.
Prevalence in other countries — The prevalence of CKD in countries other than the United States has been reported, although cross-country comparisons are difficult because of variations in study design, differences in definitions used, lack of standardization of laboratory calibrations, and lack of knowledge of significant factors such as age and comorbidity [22]. CKD, most commonly defined as an elevated serum creatinine level or decreased eGFR or moderately increased albuminuria, reportedly ranges from approximately 1 to 30 percent [23-33]. A meta-analysis of 44 country prevalence studies estimated the global prevalence of CKD at 13.4 percent (95% CI 11.7-15.1) and another meta-analysis of 33 prevalence studies at 10.4 percent in men (95% CI 9.3-11.9) and 11.8 percent in women (95% CI 11.2-12.6). CKD prevalence estimates were approximately 15 percent higher in low- and middle-income countries than in high-income countries [34,35].
As examples:
●In a population-based study in Korea, the prevalence of moderately increased albuminuria was 2.8 percent among normotensive, normoglycemic individuals and 10 and 16 percent among hypertensives and diabetics, respectively [23]. In another population-based study of Korean adults aged 20 years or older, the overall prevalence of CKD was 8.2 percent [36].
●Among adults in Iceland, the prevalence of an eGFR <60 mL/min/1.73 m2 and proteinuria was 5 and 2 percent among men, respectively, and 12 and 1 percent among women, respectively [30].
●In a report from Taiwan, the prevalence of an eGFR <60 mL/min/1.73 m2 was 7 percent [32].
●In one study, the overall prevalence of CKD in Norway, as defined by KDOQI criteria, was 10.2 percent, which is similar to that reported in the United States [37]. However, the relative risk for progression from CKD stages 3 or 4 to ESRD in US white patients compared with Norwegian patients was 2.5, suggesting that lower progression to ESRD rather than a smaller pool of individuals at risk accounts for the lower incidence of ESRD in Norway.
●In one study of 13 European countries, the adjusted prevalence of CKD 1 to 5 in the general population aged 45 to 74 years ranged from 6.3 percent in Norway to 25.6 percent in Germany. Furthermore, variation in CKD prevalence among the different countries was not fully explained by differences in the prevalence of diabetes, hypertension, and obesity in the general population [38].
●In the Chronic Kidney Disease Multinational Inventory, the prevalence of CKD among 19 European and North American countries ranged from 5.5 to 15.7 percent and that of elevated albuminuria and of eGFR <60 mL/min/1.73 m2 from 3 to 10.3 percent and 3.1 to 17.2 percent, respectively [39].
●In a population-based study from West Malaysia, the prevalence of CKD was 9 percent [40].
●The prevalence of CKD in indigenous populations appears to be higher than that reported in other populations. For example, the prevalence of CKD in indigenous communities of Manitoba, Canada and of the Northern Territory of Australia was 25.5 and 32.4 percent, respectively [41,42].
Incidence of CKD — There are limited data concerning the incidence of new-onset CKD:
●The Framingham Offspring study consisted of 1223 men and 1362 women who were initially free of pre-existing kidney disease [43]. After a mean follow-up of 18.5 years, 244 participants (9.4 percent) had developed kidney disease (defined as MDRD eGFR of <64 and 59 mL/min/1.73 m2 for men and women, respectively). The development of CKD was associated with increased age, diabetes, hypertension, smoking, obesity, and a lower baseline GFR.
●In a retrospective cohort study over a 5.5-year period of follow-up, the estimated annual incidence of CKD (defined as serum creatinine ≥1.7 mg/dL [150 micromol/L] for six months or longer) was 1700 per million population [44].
PREVALENCE OF END-STAGE RENAL DISEASE — The prevalence of end-stage renal disease (ESRD) continues to increase, although the incidence has stabilized [45]. According to the United States Renal Data System (USRDS), a total of 124,114 ESRD patients began renal replacement therapy (RRT) in the US in 2015, with an age-gender-race adjusted incidence rate of 357 per million/year [20]. The latter increased sharply in the 1980s and 1990s, leveled off in the early 2000s, and declined slightly since its peak in 2006. Likewise, 703,243 prevalent ESRD patients were receiving RRT in the US in 2015, with an adjusted prevalence rate of 2023.6 per million/year (table 2). Of these prevalent ESRD patients, 63 percent were receiving hemodialysis, 7 percent peritoneal dialysis, and 29.6 percent had a functioning kidney transplant. Despite that the number of ESRD incident cases plateaued in 2010, the number of ESRD prevalent cases continues to rise by approximately 20,000 cases per year [20].
The rising prevalence of treated ESRD can be attributed to the increase in the number of patients who start RRT each year and to the increased survival of patients with ESRD. Since the incidence rates of treated ESRD have flattened in recent years, the longer lifespans of prevalent ESRD patients may partially explain the steady growth of this population [1].
There are a paucity of data concerning the correlation of the change in prevalence (or incidence) of CKD over time with changes in the incidence of ESRD. (See 'Prevalence of CKD' above.)
However, an absolute one-to-one correlation between the prevalence of predialysis CKD and incidence of ESRD does not exist in the United States. Using data from the National Health and Nutrition Examination (NHANES) II and III surveys and the United States Renal Data System (USRDS) Registry, the incidence of ESRD appears to be increasing faster than that prevalence for CKD [46]. As an example, nine new cases of ESRD developed in 1983 for every 1000 patients with CKD in 1978. By comparison, 16 cases of ESRD had developed in 1996 for every 1000 patients with CKD in 1991. A similar finding in terms of the relative stability of CKD versus a marked increase in ESRD was noted in a second study that examined NHANES data [8].
Factors that may contribute to the greater increase in the prevalence of ESRD compared with CKD include improved survival from nonrenal diseases (particularly cardiovascular disease [CVD]) and relaxed criteria for entry into ESRD programs.
The lifetime risk of developing ESRD was estimated from a Canadian cohort of almost 3 million adults without ESRD [47]. Among individuals without ESRD at age 40 years, the lifetime risk of ESRD was 2.66 percent among men and 1.76 percent among women. The risk was higher for individuals with a reduced estimated glomerular filtration rate (eGFR): For those with eGFR 44 to 59 mL/min/1.73 m2, the lifetime risk was 7.51 and 3.21 percent for men and women, respectively. Among individuals with eGFR 60 to 89 mL/min/1.73 m2, the risk was 1.01 and 0.63 percent, respectively. Thus, based upon these estimates, approximately 1 in 40 and 1 in 60 middle-aged men and women, respectively, will develop ESRD in their lifetime.
Prevalence in other countries — In a systematic review, it was estimated that 2.618 million people worldwide received RRT in 2010 [48]. The estimated number of patients who needed RRT was between 4.902 million (95% CI 4.438-5.431 million) calculated using a conservative model and 9.701 million (95% CI 8.544-11.021 million) using a high-estimate model [48]. These estimates suggest that at least 2.284 million people might have died prematurely because RRT could not be accessed. The largest treatment gaps occur in low-income countries, particularly Asia and Africa. Worldwide use of RRT is projected to more than double to 5.439 million (95% CI 3.899-7.640 million) people by 2030, with the most growth in Asia [48].
According to the USRDS, the highest prevalence of treated ESRD was reported for Taiwan, Japan, and the US, and, in the Chronic Kidney Disease Inventory, the prevalence of treated ESRD was highest in Portugal and lowest in Switzerland [20,39].
RACIAL VARIATIONS IN PREVALENCE OF ESRD AND CKD — There are striking racial and ethnic differences in the incidence and prevalence rates of end-stage renal disease (ESRD) [49,50]. In 2005, the incidence rates for ESRD in the United States were 268 per million population in Caucasians; 991 in African Americans; 355 in Asian Americans, native Hawaiians, and other Pacific Islanders; and 516 in American Indians and Alaska Natives [49]. Examined by ethnicity, Hispanics had higher incidence rates than non-Hispanics (490 versus 337 per million population). Racial and ethnic differences persist, with 2008 incident rates in the African-American and American-Indian populations 3.6 and 1.8 times greater, respectively, than the rate among whites and the rate in the Hispanic population 1.5 times higher than that of non-Hispanics [1]. Similarly, the incidence of ESRD in South-Asian and African-Caribbean immigrants in the United Kingdom is three- to fourfold higher than in the general population [51]. Analysis of National Health and Nutrition Examination (NHANES) data suggested that, although the prevalence of stage 3 and 4 CKD stabilized among non-Hispanic white persons between 2003 to 2004 and 2011 to 2012, the prevalence among non-Hispanic black persons continued to increase [13].
There is also significant variability in the causes of ESRD among the various racial and ethnic groups. As an example, whereas diabetic nephropathy is the most common cause of ESRD in all racial/ethnic groups, hypertensive nephropathy is the cause of ESRD in 33 percent of African Americans compared with <25 percent in all other racial/ethnic groups. The age- and gender-adjusted ratio (African American to Caucasian) of hypertensive ESRD is 6:1.
African Americans and, to a lesser extent, other racial and ethnic minorities have a disproportionately higher incidence rate of ESRD due to diabetes and glomerulonephritis compared with Caucasians. Furthermore, African Americans and Hispanics tend to reach ESRD at a younger age than Caucasians (mean age 57 and 58 years, respectively, compared with 63 years). In the United Kingdom, a similarly increased risk of diabetic nephropathy is seen in the South-Asian population, whereas the African-Caribbean population also has additional susceptibility to kidney damage from hypertension and sickle cell disease [51].
Since not all patients with CKD reach ESRD, it is conceivable that the incidence and prevalence rates of earlier stages of CKD among some racial/ethnic groups differ from those observed in ESRD patients. These racial and ethnic disparities are unlikely to be purely due to genetic factors, especially since the two most common causes of ESRD (diabetes and hypertension) are highly modifiable conditions. These disparities raise the possibility that differential access to health care and, thus, management of CKD and probably faster progression to ESRD, may be a cause for concern in minority groups, particularly among African Americans [52,53].
There are limited data regarding the prevalence of CKD stratified by race and ethnicity:
●From NHANES III data, it was estimated that the prevalence of CKD (glomerular filtration rate [GFR] <60 mL/min/1.73 m2) was 5, 3.5, and 1 percent among non-Hispanic whites, non-Hispanic blacks, and Mexican Americans, respectively [54,55].
●Among participants in the Hispanic Health and Nutrition Examination Survey (HHANES), the prevalence of CKD was 13, 3, and 4 percent among Cuban Americans, Mexican Americans and Puerto Ricans, respectively [56].
●In a population-based study of the Zuni Indians, the prevalence of albuminuria (urine albumin creatinine ratio [ACR] ≥0.3) was approximately 20 percent among diabetic patients and <2 percent among nondiabetic patients [57].
APOL1 in African Americans — Genetic factors underlie, at least in part, the markedly increased risk of ESRD among African Americans. Two separate disease-causing polymorphisms, originally believed to reside in the podocyte nonmuscle myosin IIA (MYH9) gene but now known to be located in the neighboring apolipoprotein L1 (APOL1) gene [58-61], follow an autosomal recessive pattern of inheritance and confer a substantially higher risk of ESRD (10-fold higher risk of ESRD due to focal glomerulosclerosis and sevenfold higher risk of ESRD attributed to hypertension) [61-65].
APOL1 mutations are also associated with an earlier onset of kidney disease. In a study of 407 African-American patients receiving hemodialysis, patients with two mutant alleles were significantly younger at the time of dialysis initiation than those without any disease-causing APOL1 mutation (49 versus 62 years) [66]. In addition, these polymorphisms are associated with earlier stage CKD. In a population-based study that included 1776 African Americans without known kidney disease (mean age 45 years), homozygotes for APOL1 mutations were more likely to have moderately increased albuminuria (formerly called "microalbuminuria"; 18 versus 9 percent) and an estimated GFR (eGFR) <60 mL/min/1.73 m2 (6 versus 3 percent) compared with other individuals [64].
Among patients who have CKD, high-risk APOL1 alleles are associated with more rapid decline in eGFR. In post-hoc analyses of the Chronic Renal Insufficiency Cohort (CRIC) study, 2955 patients (48 percent black and 46 percent with diabetes) were analyzed by race and according to the absence or presence of high-risk APOL1 alleles [65]. Over a mean follow-up of 4.4 years, the eGFR declined faster among black patients with a high-risk APOL1 allele compared with black patients with a low-risk APOL1 allele and compared with white patients. This association was observed among diabetic patients (with declines in eGFR of -4.3 versus -2.7 and -1.5 mL/min/1.73 m2 per year, respectively) and nondiabetic patients (-2.9 versus -1.0 versus -0.7 mL/min/1.73 m2 per year, respectively).
APOL1 mutations are found exclusively among individuals of African descent and, although speculative, are believed to provide resistance to disease-causing trypanosomes. The functional significance of these gene variants is unclear, but they may lead to diminished expression of APOL1 in podocytes and inappropriate expression in renal arterioles [67].
The association of APOL1 polymorphisms with specific renal diseases is discussed separately. (See "HIV-associated nephropathy (HIVAN)" and "Clinical features, diagnosis, and treatment of hypertensive nephrosclerosis" and "Collapsing focal segmental glomerulosclerosis not associated with HIV infection" and "Focal segmental glomerulosclerosis: Epidemiology, classification, clinical features, and diagnosis".)
IMPACT OF CKD AND ESRD ON GENERAL MORBIDITY — Both early stages of CKD and end-stage renal disease (ESRD) are associated with high morbidity and increased health care utilization. Approximately 50 percent of dialysis patients have three or more comorbid conditions; the number of hospitalizations and hospital days are 1.9 and 12.8 per patient-year, respectively, and self-reported quality of life is far lower in dialysis patients than in the general population [1,49,68,69].
Importantly, many of the clinical features and outcomes observed among patients with ESRD are reported for those with earlier stages of CKD. As an example, in a retrospective analysis of 259 adult patients with CKD (defined as serum creatinine ≥1.5 mg/dL [133 micromol/L] for women and ≥2 mg/dL [177 micromol/L] for men), hypertension, diabetes, cardiovascular disease (CVD), and peripheral vascular disease were present in 87, 35, 40, and 14 percent, respectively [70]. Forty-seven percent of patients were hospitalized during a median follow-up of 11.4 months, and the number of hospitalizations and hospital days per patient-year at risk were 0.96 and 6.6, respectively. CVD (excluding congestive heart failure) and hypertension were the most common primary diagnoses, accounting for 24.5 percent of hospitalizations. In a multivariable regression analysis, older age and presence of cardiac disease were associated with higher risk of hospitalization, while higher albumin and higher hematocrit levels were associated with lower risk of hospitalization.
The results of this study highlight some general observations concerning early stages of CKD and ESRD:
●The prevalence of certain comorbid conditions among patients with earlier stages of CKD were comparable with the prevalence of these conditions in the United States dialysis population: CVD (40 versus 59 percent for dialysis patients), cerebrovascular disease (12 versus 8 percent), and peripheral vascular disease (14 and 14 percent) [71].
●The causes of hospitalization were similar to those in the US dialysis population, with the exception of vascular access hospitalizations [72,73].
●The rates of hospitalization and of hospital days per patient-year at risk were three times higher among patients with earlier stages of CKD than in the general population and approximately half when compared with those of dialysis patients [74,75].
●Risk factors for hospital utilization were similar to those observed among ESRD patients, such as older age, gender, race, cardiac disease, peripheral vascular disease, serum albumin, and hematocrit levels [72,73,76,77].
The similarity in comorbid conditions and causes of hospitalization suggest that the comorbidity and complications observed in ESRD manifest themselves well before the onset of ESRD. Similar findings were observed in a study of patients with earlier stages of CKD referred to a nephrology service in Ontario, Canada [78].
The risk of hospitalization and cardiovascular events in patients with CKD progressively increases as glomerular filtration rate (GFR) declines. In one study, GFR was estimated longitudinally from 1996 to 2000 in over one-million enrollees of a US integrated health care system [79]. The adjusted risk for cardiovascular events for patients with an estimated GFR (eGFR) of 45 to 59, 30 to 44, 15 to 29, and <15 mL/min/1.73 m2 was 1.4, 2.0, 2.8, and 3.4, respectively, and similar patterns were observed in the risk for hospitalization.
A detailed discussion of the association between CKD and morbidity from CVD is discussed separately. (See "Chronic kidney disease and coronary heart disease".)
IMPACT OF CKD AND ESRD ON MORTALITY — Patients with CKD and particularly end-stage renal disease (ESRD) are at increased risk of mortality, particularly from cardiovascular disease (CVD). In 2011 alone, more than 92,221 ESRD patients died [1,2]. Survival probabilities for dialysis patients at one, two, and five years are approximately 81, 65, and 34 percent, respectively [49]. Rates for prevalent dialysis patients ≥65 years of age are nearly seven times higher than those in the general population [1]. The Global Burden of Disease Study 2015 reported that, among 315 diseases, the rank of CKD in terms of disability-adjusted life years rose from 30 in 1990 to 22 in 2005 and 20 in 2015 [80]. This is discussed in detail separately. (See "Chronic kidney disease and coronary heart disease" and "Moderately increased albuminuria (microalbuminuria) and cardiovascular disease" and "Patient survival and maintenance dialysis".)
SUMMARY
●The overall prevalence of chronic kidney disease (CKD) increased significantly between 1999 and 2004 but stabilized in 2011, including among older individuals. (See 'Prevalence of CKD' above.)
●The prevalence of end-stage renal disease (ESRD) is growing. Reasons for the increasing prevalence of ESRD include improved survival from nonrenal diseases (particularly cardiovascular disease [CVD]) and relaxed criteria for entry into ESRD programs. (See 'Introduction' above.)
●Striking racial and ethnic differences are present in the incidence and prevalence rates of ESRD. The highest incidence is reported for African Americans; followed by American Indians and Alaska Natives; followed by Asian Americans, native Hawaiians, and other Pacific Islanders; followed by Caucasians. Hispanics have higher incidence rates of ESRD than non-Hispanics. A similar disparity has also been observed in the United Kingdom. (See 'Racial variations in prevalence of ESRD and CKD' above.)
●There is variability in the causes of ESRD among the various racial and ethnic groups. Diabetic nephropathy remains the most common cause of ESRD in all racial/ethnic groups. (See 'Racial variations in prevalence of ESRD and CKD' above.)
●Both early stages of CKD and ESRD are associated with high morbidity and increased health care utilization. The comorbid conditions and causes of hospitalization are strikingly similar between patients with early stages of CKD and ESRD, suggesting that the complications of ESRD manifest themselves well before the onset of ESRD. The risk of hospitalization and cardiovascular events in patients with CKD progressively increase as GFR declines. (See 'Impact of CKD and ESRD on general morbidity' above.)
ACKNOWLEDGMENT — The editorial staff at UpToDate would like to acknowledge Brian JG Pereira, MD, who contributed to earlier versions of this topic review.
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53 : Racial differences in the prevalence of chronic kidney disease among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Cohort Study.
54 : Chronic kidney disease in African American and Mexican American populations.
55 : Racial differences in the progression from chronic renal insufficiency to end-stage renal disease in the United States.
56 : Creatinine levels among Mexican Americans, Puerto Ricans, and Cuban Americans in the Hispanic Health and Nutrition Examination Survey.
57 : Kidney disease among the Zuni Indians: the Zuni Kidney Project.
58 : MYH9 is associated with nondiabetic end-stage renal disease in African Americans.
59 : Kidney disease and African ancestry.
60 : A risk allele for focal segmental glomerulosclerosis in African Americans is located within a region containing APOL1 and MYH9.
61 : Association of trypanolytic ApoL1 variants with kidney disease in African Americans.
62 : Polymorphisms in the non-muscle myosin heavy chain 9 gene (MYH9) are strongly associated with end-stage renal disease historically attributed to hypertension in African Americans.
63 : Non-muscle myosin heavy chain 9 gene MYH9 associations in African Americans with clinically diagnosed type 2 diabetes mellitus-associated ESRD.
64 : Population-based risk assessment of APOL1 on renal disease.
65 : APOL1 risk variants, race, and progression of chronic kidney disease.
66 : Genetic variation in APOL1 associates with younger age at hemodialysis initiation.
67 : APOL1 localization in normal kidney and nondiabetic kidney disease.
68 : Functional status and quality of life: predictors of early mortality among patients entering treatment for end stage renal disease.
69 : Hemodialysis patient-assessed functional health status predicts continued survival, hospitalization, and dialysis-attendance compliance.
70 : Health care utilization among patients with chronic kidney disease.
71 : Health care utilization among patients with chronic kidney disease.
72 : Health care utilization among patients with chronic kidney disease.
73 : Hospital utilization among chronic dialysis patients.
74 : Hospital utilization among chronic dialysis patients.
75 : National hospital discharge survey: annual summary, 1998.
76 : Risk factors for hospital utilization in chronic dialysis patients. Southeastern Kidney Council (Network 6).
77 : Relative risk and economic consequences of inpatient care among patients with renal failure.
78 : Predictors of hospitalization and death among pre-dialysis patients: a retrospective cohort study.
79 : Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization.
80 : Global, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
