Survival following parathyroidectomy among United States dialysis patients

BACKGROUND: Secondary hyperparathyroidism (SHPTH) is highly prevalent among persons with end-stage renal disease (ESRD). SHPTH has been linked to uremic bone disease, vascular calcification, and a higher risk of death. Parathyroidectomy (PTX) can dramatically reduce parathyroid hormone (PTH) and phosphate levels; however, the relationship between PTX and survival is not known. METHODS: We conducted an observational matched cohort study utilizing data from the United States Renal Database System (USRDS) in which 4558 patients undergoing a first PTX while on hemodialysis or peritoneal dialysis were individually matched by age, race, gender, cause of ESRD, dialysis duration, prior transplantation status, and dialysis modality to 4558 control patients who did not undergo PTX. Patients were followed from the date of PTX until they died or were lost to follow-up. RESULTS: The 30-day postoperative mortality rate following PTX was 3.1%. Long-term relative risks of death among patients undergoing PTX were estimated to be 10% to 15% lower than those of matched control patients not undergoing surgery. Survival curves between the 2 groups crossed 587 days following PTX. Median survival was 53.4 months (95% CI: 51.2-56.4) in the PTX group, and 46.8 months (95% CI: 44.7-48.9) in the control group. CONCLUSION: PTX was associated with higher short-term, and lower long-term, mortality rates among U.S. patients receiving chronic dialysis. Measures to attenuate SHPTH may play an important role in reducing mortality among patients with end-stage renal disease.     

Hemoglobin levels and erythropoietin doses in hemodialysis and peritoneal dialysis patients in the United States

Erythropoietic agents, a cornerstone of management, are a major component of the cost of renal replacement therapy. The objectives of this study were to compare (on a month-by-month basis) U.S. hemodialysis and peritoneal dialysis patients in terms of the proportion of patients receiving erythropoietin, erythropoietin doses, and hemoglobin levels after initiation of erythropoietin. Patients studied (hemodialysis, n = 121,970; peritoneal dialysis, n = 7129) began dialysis between 1995 and 2000, had Medicare as their primary payer, were 65 yr old or older at dialysis inception, had no erythropoietin claims before dialysis inception, and did not have a switch in dialysis modality in the first 6 mo of dialysis therapy. Total monthly erythropoietin doses and average monthly hemoglobin levels were calculated from Medicare claims. The proportion of patients who received erythropoietin plateaued at 3 mo in both groups: 25% in peritoneal dialysis patients and 80% in hemodialysis patients. However, monthly erythropoietin doses plateaued at 30,000 units in peritoneal dialysis patients and 60,000 units in hemodialysis patients, a disparity not explicable by differences in baseline characteristics. Among subjects who received erythropoietin, mean hemoglobin levels were similar at steady state in both populations and met the National Kidney Foundation Dialysis Outcomes Quality Initiative hemoglobin target level of 11 to 12 g/dl. Hemoglobin levels in U.S. hemodialysis and peritoneal populations are similar. However, erythropoietin doses are dramatically higher in hemodialysis patients.     

Survival differences among older dialysis patients in the southeast.

Older end-stage renal disease (ESRD) patients treated by chronic dialysis have higher mortality in the United States than in many other countries. While increasing age, white race, male sex, and/or diabetes are considered risk factors for survival, few studies of older dialysis patients have simultaneously considered multiple predictor variables and their interactions. Using information contained in the 1982 to 1986 ESRD Network 20 database for Georgia and South Carolina, we studied hospitalizations and survival of 1,354 blacks and 965 whites who were age 60 years or older when they began dialysis therapy. Survival time was modeled using the Cox life-table regression method. Older blacks' median age at dialysis initiation was 67.4, compared with 68.7 for older whites (P = 0.001). Blacks were more likely than whites (P < 0.001) to have hypertension-related or diabetes-related ESRD. White patients experienced approximately 25% more hospitalization when adjustment was made for patient-days at risk. Separate multivariate survival models were required for patients with diabetes-related versus non-diabetes-related ESRD. Among diabetics, mortality was higher among whites and among patients who were older when they began dialysis. Among patients with non-diabetes-related ESRD, mortality was higher among patients who were older when they began dialysis, but the age effect was much stronger for white males. Our hospitalization and mortality data support the view that unmeasured severity (or frailty) differences characterize white as compared with black dialysis patients. Among non-diabetes-related ESRD patients, the age effect on survival was more severe in white males than in blacks or in white females. The high mortality we observed among older dialysis patients in Georgia and South Carolina warrants further study; the data may in part reflect patients' lower socioeconomic status compared with age, race, and sex-matched controls.     

腹透患者和血透患者的营养状况比较

营养不良在透析患者中非常常见,占18%～55%.作为影响透析患者生存质量和生存率的一个重要指标,营养不良已不断受到人们的重视.本文通过比较营养状态的几个重要评价指标,反映在不同透析方法 (腹透和血透) 患者营养状况的差异.     

Comparison of sleep quality between hemodialysis and peritoneal dialysis patients

AIM: Sleep disorders are common in patients with end-stage renal disease. Although studies have been conducted on the type and frequency of sleep disturbances in hemodialysis and peritoneal dialysis patients, there has been no study comparing the sleep quality between these two groups. Therefore, we aimed to compare sleep quality between hemodialysis and peritoneal dialysis patients. METHODS: A total of 102 patients (52 hemodialysis and 50 peritoneal dialysis) were included in the study. The Pittsburgh sleep quality index (PSQI) was used for the assessment of sleep quality. Two groups were compared for seven components of the PSQI questionnaire and global score as well as for clinical and laboratory findings. We also assessed the independent predictors of sleep quality. RESULTS: There were 51 male and 51 female patients (29 male and 23 female in hemodialysis group versus 22 male and 28 female in peritoneal dialysis group). The mean age was 55.5 +/- 14.6 years in the hemodialysis and 51.5 +/- 18.1 years in the peritoneal dialysis group. The median dialysis duration was 36 (77.0) months. The sleep quality was poor in 88.5% of the hemodialysis patients and 78.0% of the peritoneal dialysis patients. However, this difference in sleep quality was not significant between the two groups (P > 0.05). There was a significant association between the sleep quality and the age, presence of diabetes mellitus, and serum albumin. Among these variables, only age was found to be an independent predictor of sleep quality. CONCLUSIONS: Hemodialysis and peritoneal dialysis patients had a similar high rate of poor sleep quality. Further studies are necessary to investigate the causes of poor quality of sleep and to investigate methods to improve sleep quality in this population.     

Comparison of cognitive function between patients with hemodialysis and peritoneal dialysis

Objective To evaluate whether dialysis modality will affect cognitive function in dialysis population. Methods This was a cross-sectional study. Chronic dialysis patients in our center was screened from July 2013 to July 2014. All of the subjects received brain magnetic resonance imaging (MRI) examination and comprehensive cognitive function evaluation. Results A total of 189 chronic dialysis patients were enrolled in this study, 122 cases on hemodialysis (HD) and 67 cases on peritoneal dialysis (PD). There was no significant difference in age between HD and PD groups [(56.4±13.2) years vs (56.4±16.1) years, t=0.004, P=0.997]. The dialysis vintage and serum albumin of HD patients was higher than those of PD patients[58.0(16.8, 107.5) months vs 31.0(7.0, 67.0) months, Z=-3.490, P＜0.001; (39.6±3.9) g/L vs (35.3±3.8) g/L, t=7.328，P＜0.001, respectively]. The prevalence of cerebral small vessel diseases (CSVDs) was comparable between HD and PD groups (all P＞0.05). Compared with HD patients, PD patients presented a 11.90-fold risk of immediate memory impairment (95%CI 1.40-101.08, P=0.023) and a 6.18-fold risk of long-delayed memory impairment (95%CI 2.12-18.05, P=0.001). After adjusting for age, educational lever, dialysis vintage, serum creatinine, and CSVDs, the influence of dialysis modality on memory still worked. PD patients presented a 43% risk of executive function impairment of HD patients (OR=0.43, 95%CI 0.17-1.04, P=0.061). Conclusions HD patients manifested better memory than PD patients, while PD probably performed better in executive function than HD patients. There was no significant difference in language function between the two groups. The difference in cognitive function may not be related to CSVDs.     

Survival analysis in automated peritoneal dialysis patients

Objectives To compare the clinical characteristics, long-term survival and associated risk factors of automated peritoneal dialysis (APD) patients and continuous ambulatory peritoneal dialysis (CAPD) patients. Methods As a retrospectively study, adult patients started peritoneal dialysis in Peking Union Medical College Hospital (PUMCH) from September 1st, 2002 to September 30th, 2016 were enrolled. Baseline information and dialysis associated parameters were collected. The primary outcome was death and the secondary outcome was technical failure. The risk factors of death were analyzed in APD patients by Cox's regression model. Homochromous gender and age matched CAPD patients were analyzed as control. Results The baseline condition of 69 APD patients were similar to those of 138 CAPD patients. The survival rates of APD patients at 1-year、3-year and 5-year were 95.4%, 88.0% and 73.0% respectively, which were superior to CAPD patients. No significant difference in technical survival was found between APD and CAPD patients. Single-factor Cox's regression analysis showed that all-cause mortality of CAPD patients was 2.2 times higher than that of APD patients (95% CI 1.221-3.837). In the multi-factor Cox regression analysis model, adjusted by age, complications (including cardiovascular disease and diabetes), nPCR and serum creatinine, dialysis modality was not an independent risk factor of dialysis patients. Age (HR=1.077, 95%CI 1.016-1.142, P=0.013), diabetes (HR=3.608, 95%CI 1.117-11.660, P=0.032) and serum albumin (HR=0.890, 95%CI 0.808-0.982, P=0.020) were independently associated with all-cause death of APD patients. Conclusions Dialysis modality was not an independent risk factor for the all-cause mortality of peritoneal dialysis patients. Age, diabetic nephropathy and hypoalbuminemia were independently associated with the death of APD patients.     

Mortality in end-stage renal disease: a reassessment of differences between patients treated with hemodialysis and peritoneal dialysis

Recent registry studies comparing mortality between peritoneal dialysis (PD) and hemodialysis (HD) patients show conflicting results. The purpose of this study is to determine whether previously published results showing higher mortality for patients treated with PD versus HD in the United States continue to hold true over the period 1987-1993. National mortality rates for PD and HD were extracted from the U.S. Renal Data System (USRDS) annual reports for the cohort periods: 1987-1989, 1988-1990, 1989-1991, 1990-1992, and 1991-1993. Using Poisson regression, death rates per 100 patient years were compared between PD and HD for each cohort period controlling for age, gender, race, and cause of end-stage renal disease (diabetes versus nondiabetes). When incident patients and patients with a prior transplant were included in the analysis, starting with the 1989-1991 cohort, we found little or no difference in the relative risk (RR PD:HD) of death between PD and HD (1987-1989: RR = 1.17, P < 0.001; 1988-1990: RR = 1.12, P < 0.001; 1989-1991: RR = 1.06, P = NS; 1990-1992: RR = 1.06, P = NS; 1991-1993: RR = 1.08, P = 0.043). After a test for goodness-of-fit, separate analyses for diabetic patients and nondiabetic patients were done to examine unexplained variation in death rates. For nondiabetic patients, there was less than a 1% difference in the adjusted 1-yr survival between PD and HD from 1989-1993 (1989-1991: RR = 1.05, P = NS; 1990-1992: RR = 1.04, P = NS; 1991-1993: RR = 1.07, P < 0.01). Among diabetic patients, the PD:HD death rate ratio varied significantly according to gender and age. For the average male diabetic patient, there was little or no difference in risk between PD and HD from 1989-1993 (1989-1991: RR = 1.02, P = NS; 1990-1992: RR = 1.05, P = NS; 1991-1993: RR = 1.08, P < 0.01). For diabetic patients under the age of 50, those treated with PD had a significantly lower risk of death than those treated with HD (1989-1993: 0.84 < or = RR < or = 0.89, P < 0.005). Over the same period, female diabetic patients treated with PD had a higher risk, on average, than HD (1.18 < or = RR < or = 1.19, P < 0.001) as did diabetic patients over the age 50 (1.28 < or = RR < or = 1.30, P < 0.001). Unlike previously published results that were restricted to prevalent-only patients, this national study of both prevalent and incident patients found little or no difference in overall mortality between PD and HD. The recent trends in mortality likely reflect the inclusion of incident patients, but they may also reflect changes in case-mix differences and/or improved PD practice. Additional incident-based studies that allow for additional case-mix adjustments are needed to better compare outcomes between HD and PD.     

Patient and technique survival on peritoneal dialysis in the United States: evaluation in large incident cohorts

Patient and technique survival on peritoneal dialysis in the United States: Evaluation in large incident cohorts. Secular trends in dialysis require a frequent re-examination of outcomes in patients on renal replacement modalities. We examined three large cohorts of patients initiating peritoneal dialysis (PD) in 1999, 2000, and 2001 (total of > 30,000 patients) to ascertain trends in patient outcomes, technique success, and predictors of both parameters of interest. Trends toward improved patient survival, higher technique success, and increasing use of cycler-based therapy, with more recent calendar years were noted. Age and diabetes were clear predictors of patient survival, but did not appear to influence technique success. Technique success was higher in patients on automated PD (APD) than in patients on continuous ambulatory PD (CAPD), but this difference was mostly concentrated in the first year on therapy. Patients starting PD after a failed allograft had excellent survival. We conclude that the current state of PD in the United States is characterized by improving patient outcomes, higher technique success, and a predominance of use of cycler-based therapy. Several opportunities for improving technique success amenable to practice interventions have been identified. The high success of PD in patients with failed allograft suggests that it is beneficial to utilize this modality more frequently in this patient group than current practice.     

Body size and outcomes on peritoneal dialysis in the United States

BACKGROUND: Being overweight is often cited as a relative contraindication to peritoneal dialysis. Our primary objective was to determine whether actual mortality rates support this opinion. METHODS: Retrospective cohort study of United States Medicare patients initiating dialysis between 1995 and 2000 (N = 418,021; 11% peritoneal dialysis). RESULTS: Seven percent were underweight [body mass index (BMI) < 18.5 kg/m2], 27% were overweight (BMI 25.0 to 29.9 kg/m2), and 23% were obese (BMI> 29.9 kg/m2) at dialysis initiation. Compared to those with normal BMI, the adjusted odds of initiating peritoneal dialysis were 0.70 (P < 0.05) in underweight, 1.12 (P < 0.05) in overweight, and 0.87 (P < 0.05) in obese subjects. Among peritoneal dialysis patients, adjusted mortality hazard ratios in the first, second, and third year were 1.45 (P < 0.05), 1.28 (P < 0.05), and 1.17 for the underweight, respectively; 0.84 (P < 0.05), 0.89 (P < 0.05), and 0.98 for the overweight, respectively; and 0.89 (P < 0.05), 0.99, and 1.00 for the obese, respectively. Apart from higher third-year mortality in the obese, associations were similar after censoring at a switch to hemodialysis. For transplantation, the corresponding results were 0.76 (P < 0.05), 0.90 (P < 0.05), and 0.88 for the underweight, respectively; 0.95, 1.06, and 0.93 for the overweight, respectively; and 0.62 (P < 0.05), 0.68, and 0.71 for the obese, respectively. For switching to hemodialysis, hazards ratios were 0.92, 0.97, and 0.80 for the underweight, respectively; 1.07, 1.11 (P < 0.05), and 1.03 for the overweight, respectively; and 1.28 (P < 0.05), 1.29 (P < 0.05), and 1.36 (P < 0.05) for the obese, respectively. CONCLUSION: Although less likely to initiate peritoneal dialysis, overweight and obese peritoneal dialysis patients have longer survival than those with lower BMI, not adequately explained by lower transplantation and technique survival rates.     

Anemia, hospitalization, and mortality in patients receiving peritoneal dialysis in the United States

BACKGROUND: The view that hemoglobin levels in peritoneal dialysis patients should be maintained at 11 to 12 g/dL is based largely on the results of studies in hemodialysis patients. METHODS: We studied 13,974 erythropoietin-treated Medicare patients who initiated peritoneal dialysis between 1991 and 1998. Mean hemoglobin levels for the first 6 months of the study and, subsequently, time to first hospitalization and death during a 2-year follow-up were determined. RESULTS: The percentages of patients with hemoglobin levels of <10, 10 to 10.9, 11 to 11.9, and >/=12 g/dL were 24.6%, 40.6%, 27.6%, and 7.2%, respectively. First-hospitalization and death rates, respectively, were 109.5 and 21.6 per 100 patient-years in nondiabetic patients, and 152.9 and 31.5 in diabetic patients. In nondiabetic patients, adjusted hospitalization hazard ratios for hemoglobin levels of <10, 10 to 10.9, 11 to 11.9 (reference category), and >/=12 g/dL were 1.29 (P < 0.0001), 1.15 (P < 0.0001), 1, and 0.98 (NS), respectively. The corresponding adjusted mortality hazard ratios were 1.43 (P < 0.0001), 1.13 (P < 0.05), 1, and 1.14 (NS). In diabetic patients, hazard ratios of 1.26 (P < 0.0001), 1.07 (NS), 1, and 0.82 (P < 0.01) were observed for hospitalization, and 1.34 (P < 0.0001), 1.18 (P < 0.01), 1, and 0.92 (NS) for mortality. CONCLUSION: In peritoneal dialysis patients, anemia is associated with hospitalization and mortality in a manner supporting current Kidney Dialysis Outcomes Quality Initiative (K/DOQI) hemoglobin targets. In addition, hemoglobin levels of >/=12 g/dL are associated with lower hospitalization rates in diabetic patients.     

血液透析与腹膜透析患者微炎症反应比较及其与营养状况、心血管疾病关系的研究

目的 研究血液透析、腹膜透析两种透析方式对慢性肾衰尿毒症患者微炎症状态的影响,探讨微炎症状态与营养状况、心血管疾病的关系.方法 选择2011年1月至2012年6月沈阳市红十字会医院肾内科住院的尿毒症患者64例(血液透析30例、腹膜透析34例)及健康对照者30例,检测C反应蛋白、白介素6、尿素氮、肌酐、白蛋白、前白蛋白、血红蛋白,计算体重指数.根据主观综合性营养评价将患者分为营养良好组、营养不良组.记录透析处方和心血管并发症.结果 本组尿毒症患者C反应蛋白、白介素6较对照组显著升高(P＜0.01),血液透析组C反应蛋白、白介素6显著高于腹膜透析组(P＜0.05).尿毒症各组内营养良好组C反应蛋白、白介素6较营养不良组显著升高(P＜0.05),合并慢性心衰组C反应蛋白、白介素6较无心衰并发症组显著升高(P＜0.05).C反应蛋白与白蛋白、前白蛋白呈显著负相关,与尿素氮、肌酐、血红蛋白无显著相关性.结论 血液透析患者微炎症状态比腹膜透析患者严重,尿毒症患者微炎症状态与营养不良及心血管疾病密切相关.     

Patient mortality in chronic dialysis: comparisons between hemodialysis and peritoneal dialysis

Patients with approaching end-stage renal disease often must choose between hemodialysis or peritoneal dialysis as the initial form of renal replacement therapy. Should nephrologists recommend one form of dialysis as superior to the other? This review focuses on studies that compared patient mortality for these two dialysis techniques. Explanations for the disparate findings of these studies will be put forth. Finally, suggestions regarding what we can recommend to patients are made.     

Carpal tunnel syndrome in dialysis patients: comparison between continuous ambulatory peritoneal dialysis and hemodialysis populations

Carpal tunnel syndrome (CTS) has been reported with increased frequency in hemodialysis (HD) patients. A comparative study of patients on continuous ambulatory peritoneal dialysis (CAPD) has not been previously reported. To delineate the significance of dialytic modality and access-related risk factors, this study investigated the incidence and patient characteristics of CTS in CAPD v HD populations. One hundred and fifty one patients (HD n = 90, CAPD n = 61) were evaluated by questionnaire, physical examination, and nerve conduction studies. Age, gender, renal diagnosis, access, diabetic history, and duration of dialysis were determined. Eight of 57 CAPD and 15/83 HD patients had CTS. chi 2 testing revealed no significant difference in incidence (P = 0.7). It is concluded that CTS occurs with similar incidence in CAPD and HD populations. Dialytic modality and access are not likely to be factors in the development of CTS. Rather, CTS is a metabolic complication of end-stage renal failure.     

Mortality differences by dialysis modality among incident ESRD patients with and without coronary artery disease

It is unclear whether peritoneal dialysis (PD) compared with hemodialysis (HD) confers a survival advantage in end-stage renal disease (ESRD) patients with coronary artery disease (CAD). This hypothesis was tested in a national cohort of 107,922 patients starting dialysis therapy between May 1, 1995, and July 31, 1997. Data on patient characteristics were obtained from the Center for Medicare and Medicaid Services Medical Evidence Form (CMS) and linked to mortality data from the United States Renal Data System (USRDS). Patients were classified on the basis of CAD presence and followed until death or the end of 2 yr. Nonproportional Cox regression models estimated the relative risk (RR) of death for patients with and without CAD by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetic patients (DM) and nondiabetic patients (non-DM) were analyzed separately. Among DM, patients with CAD treated with PD had a 23% higher RR (95% CI, 1.12 to 1.34) compared with similar HD patients, whereas patients without CAD receiving PD had a 17% higher RR (CI, 1.08 to 1.26) compared with HD. Among non-DM, patients with CAD treated with PD had a 20% higher RR (CI. 1.10 to 1.32) compared with HD patients, whereas patients without CAD had similar survival on PD or HD (RR = 0.99; CI, 0.93 to 1.05). The mortality risk for new ESRD patients with CAD differed by treatment modality. In both DM and non-DM, patients with CAD treated with PD had significantly poorer survival compared with HD. Whether differences in solute clearance and/or cardiac risk profiles between PD and HD may explain these findings deserves further investigation.     

Impact of dialysis modality on survival of new ESRD patients with congestive heart failure in the United States

BACKGROUND: It is hypothesized, but not proven, that peritoneal dialysis might be the optimal treatment for end-stage renal disease (ESRD) patients with established congestive heart failure (CHF) through better volume regulation compared with hemodialysis. METHODS: National incidence data on 107,922 new ESRD patients from the Center for Medicare and Medicaid Services (CMS) Medical Evidence Form were used to test the hypothesis that peritoneal dialysis was superior to hemodialysis in prolonging survival of patients with CHF. Nonproportional Cox regression models evaluated the relative hazard of death for patients with and without CHF by dialysis modality using primarily the intent-to-treat but also the as-treated approach. Diabetics and nondiabetics were analyzed separately. RESULTS: The overall prevalence of CHF was 33% at ESRD initiation. There were 27,149 deaths (25.2%), 5423 transplants (5%), and 3753 (3.5%) patients lost to follow-up over 2 years. Adjusted mortality risks were significantly higher for patients with CHF treated with peritoneal dialysis than hemodialysis [diabetics, relative risk (RR) = 1.30, 95% confidence interval (CI) 1.20 to 1.41; nondiabetics, RR = 1.24, 95% CI 1.14 to 1.35]. Among patients without CHF, adjusted mortality risk were higher only for diabetic patients treated with peritoneal dialysis compared with hemodialysis (RR = 1.11, 95% CI 1.02 to 1.21) while nondiabetics had similar survival on peritoneal dialysis or hemodialysis (RR = 0.97, 95% CI 0.91 to 1.04). CONCLUSION: New ESRD patients with a clinical history of CHF experienced poorer survival when treated with peritoneal dialysis compared with hemodialysis. These data suggest that peritoneal dialysis may not be the optimal choice for new ESRD patients with CHF perhaps through impaired volume regulation and worsening cardiomyopathy.     

Projecting the United States ESRD population: issues regarding treatment of patients with ESRD

In 2001, there were 406,081 patients who received treatment for end-stage renal disease (ESRD), increasing by 4.2% since 2000. The number of patients with ESRD has grown consistently over the past decade, with the greatest rate of growth occurring among patients older than 75 years of age, and patients with comorbidities such as diabetes mellitus and hypertension. Current projections indicate that the population of patients with ESRD may reach more than 2 million by 2030. The overall mortality rate has fallen by 10% since 1988, with the greatest decline among patients incident to dialysis, and an increase among patients receiving dialysis for greater than five years. While the rate of hospitalization for ESRD patients has remained relatively constant, recent improvements in mortality are temporally associated with a greater proportion of patients achieving adequate benchmarks of care in dialytic processes, such as anemia correction and dose of dialysis. The ESRD program consumes 6.4% of the Medicare budget. On a per-patient per month basis, Medicare costs have risen between 1991 and 2001. While payments fell slightly during 1998 and 1999 because of changes in Medicare policies, more recent years have seen an upswing in total expenditures, presumably related to use of injectables not included in the composite rate. Continued growth in the number of new patients reaching ESRD, as well as improved mortality rates of ESRD patients, are both contributing to the current rise and projected epidemic of ESRD over the next 25 years. The current public health strategy of identification of patients with early kidney disease to slow their progression to ESRD, in addition to aggressive treatment strategies to minimize the morbidity and mortality of patients with ESRD, is essential toward affecting the growth and health of this population.