Patients with end-stage renal disease (ESRD) are surviving longer, and fewer will succumb during their first year on dialysis than in the past, according to the 20th annual report of the US Renal Data System.
First year mortality rates have fallen by almost 30% in peritoneal dialysis patients, 5% in the haemodialysis population, and 16% for transplant recipients since 1998. Evidence suggests that better treatment of cardiovascular disease and fewer serious infections account in large part for the superior outcomes.
However, with baby boomers now entering their 60s, the number of new patients in the US requiring dialysis or kidney transplants grew more than three percent in 2006, with numbers exceeding 110,000.
Although only 1.1% of the US Medicare population had ESRD in 2006, costs for its treatment made up 6.4% of the Medicare budget that year – more than US$23 billion.
Even more money is spent in the private sector. For example, said Dr Bryan Becker, National Kidney Foundation President, "There is nearly a $17,000 difference in costs for ESRD between Medicare and employer group health plan patients per year. The reasons for this are uncertain and deserve further in-depth examination."
"Strikingly, there has been little progress in the five-year survival of paediatric ESRD patients over the last ten years," Dr Becker emphasised.
"Indeed, in some groups, the likelihood of survival declined slightly between the 1990s and the first half of this decade."
When it comes to kidney disease, children are not just "little adults". Many of these children have hereditary, autoimmune, or rare diseases. By contrast, ESRD in adults is often secondary to diabetes and high blood pressure.
"Because of the complexity of delivering ESRD care to paediatric patients and the interface between a different set of disease processes and ESRD (in contrast to the adult population), we need to pay careful attention to improving outcomes in this special population," Dr Becker said.
Transplantation remains the treatment of choice for paediatric ESRD and confers a survival advantage. More than 800 children in the US received kidney transplants in 2006, a rate four times higher than in 1980. At 20–30 percent, rates of graft failure or death after five years are similar to rates among adults.
Better patient education and increased vigilance in treating hypertension, reducing other cardiovascular risk factors and controlling blood glucose in patients with diabetes, all could slow the transition from chronic kidney disease to ESRD and cut costs.
Use of home haemodialysis is "resurging", the report indicates.
"Patient contribution to care and autonomy are key factors that appear to be important in any patient doing well with a chronic illness, and ESRD is no different," Dr Becker said.
"To the extent that home dialysis offers more patient oversight of care, this would likely improve quality of life and potentially enhance survival."
"The economic benefits of such growth could be manifest in fewer hospitalisations, reductions in certain medications, and in patients continuing to participate in their workplace and in their community."
(Source: National Kidney Foundation: Atlas of chronic kidney disease and end-stage renal disease. US Renal Data System 2008 Annual Data Report.: November 2008)