Higher Rates Of End-stage Renal Disease Research Articles

Incidence, Prevalence, and Mortality of Lupus Nephritis: A Population-Based Study Over Four Decades Using the Lupus Midwest Network.

There is a paucity of population-based studies investigating the epidemiology of lupus nephritis (LN) in the US and long-term secular trends of the disease and its outcomes. We aimed to examine the epidemiology of LN in a well-defined 8-county region in the US. Patients with incident LN between 1976 and 2018 in Olmsted County, Minnesota (1976-2009) and an 8-county region in southeast Minnesota (2010-2018) were identified. Age- and sex-specific incidence rates and point prevalence over 4 decades, adjusted to the projected 2000 US population, were determined. Standardized mortality ratios (SMRs), survival rates, and time to end-stage renal disease (ESRD) were estimated. There were 72 patients with incident LN between 1976 and 2018, of whom 76% were female and 69% were non-Hispanic White. Mean ± SD age at diagnosis was 38.4 ± 16.24 years. Average annual LN incidence per 100,000 population between 1976 and 2018 was 1.0 (95% CI 0.8-1.3) and was highest in patients ages 30-39 years. Between the 1976-1989 and 2000-2018 time periods, overall incidence of LN increased from 0.7 to 1.3 per 100,000, but this was not statistically significant. Estimated LN prevalence increased from 16.8 per 100,000 in 1985 to 21.2 per 100,000 in 2015. Patients with LN had an SMR of 6.33 (95% CI 3.81-9.89), with no improvement in the mortality gap in the last 4 decades. At 10 years, survival was 70%, and 13% of LN patients had ESRD. The incidence and prevalence of LN in this area increased in the last 4 decades. LN patients have poor outcomes, with high rates of ESRD and mortality rates 6 times that of the general population.

An analysis of hot spots of ESRD in the United States: Potential presence of CKD of unknown origin in the USA?

We hypothesized that high incidence rates of end-stage renal disease (ESRD) in certain counties of the U.S. are partly due to patients with a type of ESRD resembling chronic kidney disease of uncertain etiology (CKDu), which has been observed in Central America and other countries. Using data on 338,126 incident ESRD patients from the United States Renal Data System (USRDS) (2011-2013) and the Behavior Risk Factor Surveillance System (BRFSS) Supplement on county-level variables (2006), we describe both patient-level and county-level characteristics in counties with the highest quartile of ESRD incidence rate standardized for age, sex, and race (> 420 cases/million population/year) compared to the rest of the U.S. and two specific "hotspots" of ESRD: the San Joaquin Valley and the Rio Grande Valley. Logistic regression was used to examine characteristics associated with patients who had either missing cause of ESRD or "unknown" listed as the primary cause of ESRD. High incidence rates of ESRD were observed in southern Texas, the Southeast and parts of California (including the San Joaquin valley area), while low rates were seen in the Northwest and the Mountain Regions. The median crude incidence rate of ESRD was 335 (range 0-2,341) new cases per million population per year among counties. Significant predictors of missing/unknown primary cause of ESRD included: older age, white or unknown race, non-Hispanic ethnicity, lack of comorbidities at ESRD onset, lower estimated glomerular filtration rate (eGFR) at initiation, and lack of pre-dialysis care. Large areas of the U.S. have very high rates of ESRD incidence. We cannot confirm that CKDu is present in the U.S. based on this preliminary work. This topic therefore requires further investigation, as many of these patients may well be undocumented aliens working as farm laborers and therefore not registered in the USRDS. .

ESRD and ESRD-DM associated with lignite-containing aquifers in the U.S. Gulf Coast region of Arkansas, Louisiana, and Texas.

Balkan endemic nephropathy (BEN) is an irreversible, lethal kidney disease that occurs in regions of the Balkans where residents drink untreated well water. A key factor contributing to the development of BEN may be consumption of dissolved organic matter leached from low-rank coal called lignite. This hypothesis-known as lignite-water hypothesis-was first posed for areas of the Balkans. It is possible that a BEN-like condition exists in the United States (US) Gulf Coast region in parts of the Mississippi Embayment and the Texas Coastal Uplands aquifers -Arkansas, Louisiana, and Texas, for instance-that rely heavily on groundwater from aquifers that contain lignite. This study utilizes a geographic information system (GIS) to map the distributions of end-stage renal disease (ESRD) in relation to water from lignite-containing aquifers in the tri-state region. Regional patterns emerged from geospatial analysis, suggesting that counties that relied on lignite-containing aquifers for their main water source had higher rates of ESRD in comparison to other populations in the region that rely on other water sources, including surface water and groundwater from aquifers not associated with lignite seams. Statewide rates of ESRD and diabetes associated ESRD (ESRD-DM) showed strong correlations to the percent of families at or below poverty level and the percentage of African Americans. These confounding factors somewhat mitigate the association seen between ESRD and lignite-containing regions at the state level. However, at the larger tri-state view, there is a significant (p = 0.002) increase in incidence rates where groundwater is connected to lignite-containing aquifers when considering both race and poverty. Additionally, no relationship was observed between the rate of public water supply withdrawal from lignite-bearing aquifers and rates of ESRD or ESRD-DM at the state or tri-state regions, supporting the observation that the risk associated with water from lignite-containing aquifers is limited to water from untreated domestic supply.

A validation study of crescents in predicting ESRD in patients with IgA nephropathy

BackgroundA working group on the Oxford classification of IgA nephropathy (IgAN) recently reported that crescents detected in kidney tissue predicted a worse renal outcome. However, this finding must be validated in independent cohorts before it can be widely applied to clinical practice.MethodsBiopsy-proven IgAN patients were continuously recruited from two large renal centers in China from 1989 to 2014. All patients were followed for more than 1 year unless end stage renal disease (ESRD) occurred within 12 months. Crescents were defined as focal cellular or fibrocellular crescent formations. IgAN patients without detectable crescents were recruited to the C0 group. Patients with crescents in less than or more than 1/4 of all glomeruli were recruited to the C1 or C2 group, respectively. Primary outcome was defined as the time to ESRD, and the secondary outcome was defined as the time to an estimated glomerular filtration rate (eGFR) decline equal to or greater than 50% or to ESRD.ResultsIn total, 1152 IgAN patients were recruited in this study. Among all patients, 53.7% were in the C0 group, 38.8% were in the C1 group, and 7.5% were in the C2 group. Compared to patients in the C0 group, patients in the C1 or C2 group were younger, had more urinary protein excretion and lower eGFR, and presented with more severe mesangial hypercellularity, endocapillary proliferation or tubular atrophy/interstitial fibrosis. After 45 months of follow-up, ESRD had occurred in 80 (12.9%), 46 (10.3%) and 18 (20.9%) of patients in the C0, C1 and C2 groups, respectively. By multivariable Cox regression analysis, inclusion in the C1 (HR = 1.07, 95% CI 0.71–1.63), C2 (HR = 0.84, 95% CI 0.41–1.73), or C1 or C2 group (HR = 1.02, 95% CI 0.68–1.52) was not associated with a higher rate of ESRD than inclusion in the C0 group after adjusting for age, gender, eGFR, mean arterial pressure (MAP), MEST scores, and immunosuppressive treatment. However, in patients with nephrotic-range proteinuria, patients in either the C1 or C2 group had a higher rate of the primary outcome, ESRD (HR = 2.54, 95% CI 1.14–5.66) after adjusting for age, gender, eGFR, MAP, MEST scores, and immunosuppressive treatment. Similar results were found when we evaluated the association between crescents and the secondary outcome.ConclusionsIgAN patients with crescents had more severe clinical and pathological manifestations than those without crescents. However, we failed to replicate the association between crescents and renal function progression in Chinese IgAN patients followed for more than 1 year.

Abstract MP09: Geographic Disparities in Rates of End-Stage Renal Disease and Organ Supply in Gulf States Compared to Non-Gulf States

Background: Organ Procurement Organizations are responsible for procuring and allocating organs for transplantation from deceased donors in Donation Service Areas (DSAs). The Final Rule prohibits geographic disparities in access to organs, but the current kidney allocation system does not account for potential supply variations based on disease burden and other population characteristics within DSAs. As such, regions with traditionally high rates of comorbid disease, such as the Gulf States region, may be disadvantaged if local supply is limited. Methods: Using data from the 2016 Robert Wood Johnson Foundation County Health Rankings, the Scientific Registry of Transplant Recipients public reports, and the United States Renal Data System, we compared comorbid disease prevalence, rates of end-stage renal disease (ESRD), and expected organ donation rates by Gulf States location. Results: Prevalence of African American ethnicity, diabetes, fair/poor self-rated health, physical inactivity, food insecurity, and uninsurance were higher among DSAs in the Gulf States region vs. non-Gulf States (Table). Conversely, the prevalence of non-Hispanic White ethnicity, college education, and median household income were higher among non-Gulf States. The rate of ESRD varied by DSA, ranging from < 162 cases per 100,000 to > 225 cases per 100,000 (Figure). Median rate of ESRD was 214.4 per 100,000 among DSAs in the Gulf States, vs. 187.1 per 100,000 in the non-Gulf States (p=0.003). Expected rate of organ donation per 100 eligible deaths was 71.1 in Gulf States and 75.4 in non-Gulf States (p=0.01). Conclusion: Higher rates of ESRD were observed in the Gulf States region, suggesting a greater need for organs than non-Gulf States. However, fewer donors were estimated in Gulf States, likely due to high comorbid disease burden, compared to non-Gulf States. These data suggest the need to examine allocation policy to prevent geographic disparities in access to deceased donor transplantation.

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society.

End-stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non-Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre-ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.

Focal and segmental glomerulosclerosis: does prognosis vary with the variants?

Focal and segmental glomerulosclerosis (FSGS) is a clinicopathological entity. The following five FSGS variants: Collapsing, cellular, glomerular tip, peri-hilar and not otherwise specified (NOS) are recognized, which may have prognostic value. The aim of this study was to highlight the clinical course and outcome in the different pathological variants of FSGS and to evaluate the predictive risk factors of end-stage renal disease (ESRD). It was a retrospective analysis of biopsy-proven primary FSGS patients who presented over a period of three years. The data were collected from the clinical and biopsy records of the Nephrology Unit. There were 116 patients with biopsy-proven FSGS. The frequency of occurrence of FSGS among all cases of the nephrotic syndrome seen in our unit was 35.47%. NOS was the most common pathological variant (62.2%), followed by peri-hilar (11.2%), cellular (9.4%) and glomerular tip (7.7%), and the least common variant was collapsing (4.3%). Majority of patients with collapsing, NOS and glomerular tip variants had nephrotic range proteinuria. However, the amount of proteinuria was highest in the glomerular tip and collapsing variants. A higher percentage of patients with the collapsing and cellular variants had renal failure at the time of presentation. A higher rate of tubular and interstitial changes was seen in the collapsing and cellular variants. The collapsing and cellular variants showed lower response rate and higher rates of ESRD, while the glomerular tip lesion had the highest remission rate and the lowest rate of ESRD. Poor prognostic factors for ESRD in FSGS were initial renal insufficiency, severe tubulo-interstitial change, initial nonresponsiveness to steroids and collapsing histopathological variant. Our study suggests that histopathological classification of FSGS is of paramount importance in the management and in predicting the prognosis.

Retinopathy and clinical outcomes in patients with type 2 diabetes mellitus, chronic kidney disease, and anemia

ObjectiveRetinopathy is an established microvascular complication of type 2 diabetes mellitus (T2DM), but its independent relationship with macrovascular and other microvascular complications is less well defined across the spectrum of...

Abstract P153: Racial Disparities in Diabetic Complications in a Middle and Low Income Population of Louisiana

Background: Although coronary heart disease (CHD), heart failure (HF), stroke, and end-stage renal disease (ESRD) are major microvascular and macrovascular complications of diabetes, they are less clear for diabetic subgroups especially on those with middle and low income. Aim: To investigate racial disparities in the incidence of diabetic complications in middle and low income adults. Methods: We performed a prospective cohort study (1985-2010) on diabetic patients enrolled in the LSU Hospital-Based Longitudinal Study. Study cohorts included 89,353 diabetic patients (16,326 White men, 21,496 White women, 19,422 African American men and 32,109 African American women) who were 30 to 96 years of age. We calculated the gender specific age-standardized incident rates using the direct method to the year 2010 Census population. Cox proportional hazard models were used to compare racial or gender specific hazard ratios for CHD, HF, stroke and ESRD after adjustment for age, race, type of health insurance, family income, body mass index, smoking, systolic blood pressure, LDL cholesterol, HDL cholesterol, HbA 1c , estimated GFR, albuminuria, and drug treatments for diabetes, hypertension and hyperlipidemia. Results: During an average 4.0 years of follow-up, 16,935 CHD, 13,421 HF, 6,804 stroke, and 13,281 ESRD incident cases were ascertained. The age-standardized incident rates of the four diabetic complications are presented in table 1 . Compared with White diabetic patients, African Americans experienced higher rates of ESRD and lower rates of CHD, HF, and stroke. Female diabetic patients had lower rates of the four complications than males. Results of the Cox proportional hazard models confirmed the racial disparity and gender difference we found in the age-standardized incident rates. Conclusions: The results support the existence of racial differences in the incidence of diabetic complications in this population. Table 1 Age-adjusted incident rates of type 2 diabetes complications in the LSUHLS study Age-standardized incident rates White African American Male Female Male Female Coronary Heart Disease 101.6 (98.8-104.5) 62.0 (60.4-63.7) 50.7 (49.2-52.2) 44.4 (43.4-45.5) Heart Failure 54.9 (52.9-56.8) 41.9 (40.6-43.1) 43.4 (42.0-44.8) 38.4 (37.4-39.3) Stroke 22.1 (20.9-23.3) 20.7 (19.8-21.6) 19.9 (19.0-20.8) 18.5 (17.8-19.1) End-stage Renal Disease 43.3 (41.6-45.0) 33.4 (32.2-34.5) 51.4 (50.0-52.9) 35.2 (34.3-36.1)

Association Between Cardiac Biomarkers and the Development of ESRD in Patients With Type 2 Diabetes Mellitus, Anemia, and CKD

In patients with chronic kidney disease (CKD), as in other populations, elevations in cardiac biomarker levels predict increased risk of cardiovascular events. We examined the value of troponin T (TnT) and N-terminal pro-brain natriuretic peptide (NT-pro-BNP) in assessing the risk of developing end-stage renal disease (ESRD) in diabetic patients with CKD. Prospective cohort study nested within a randomized clinical trial. Patients with type 2 diabetes, CKD (estimated glomerular filtration rate [eGFR], 20-60 mL/min/1.73 m(2)), and anemia enrolled in TREAT (Trial to Reduce Cardiovascular Events With Aranesp Therapy). Serum levels of the cardiac biomarkers TnT and NT-pro-BNP. Incidence of ESRD and the composite of death or ESRD. We measured TnT and NT-pro-BNP in baseline serum samples from the first 1,000 patients enrolled in TREAT. The relationship of these cardiac biomarker levels to the development of ESRD and death or ESRD was analyzed in multivariable regression models. Detectable TnT (≥0.01 ng/mL) was present in 45% of participants, and median NT-pro-BNP level was elevated at 605 pg/mL. Higher levels of both cardiac biomarkers were associated independently with higher rates of ESRD, as well as death or ESRD, and remained prognostically important after adjustment for eGFR, proteinuria, and other known predictors of CKD progression. The addition of cardiac biomarkers to a multivariable model for prediction of ESRD improved discrimination of those with and without an event by 16.9% (95% CI, 6.3%-27.4%). Observational study in a clinical trial cohort; results require validation. In ambulatory patients with type 2 diabetes, anemia, and CKD, TnT and NT-pro-BNP levels frequently are elevated. These cardiac-derived biomarkers enhance prediction of ESRD beyond established risk factors. Measurement of TnT and NT-pro-BNP may improve the identification of patients with CKD who are likely to require renal replacement therapy, supporting a link between cardiac injury and the development of ESRD.

Heterogeneity of Diabetes Outcomes Among Asians and Pacific Islanders in the U.S.

OBJECTIVEEthnic minorities with diabetes typically have lower rates of cardiovascular outcomes and higher rates of end-stage renal disease (ESRD) compared with whites. Diabetes outcomes among Asian and Pacific Islander subgroups have not been disaggregated.RESEARCH DESIGN AND METHODSWe performed a prospective cohort study (1996–2006) of patients enrolled in the Kaiser Permanente Northern California Diabetes Registry. There were 64,211 diabetic patients, including whites (n = 40,286), blacks (n = 8,668), Latinos (n = 7,763), Filipinos (n = 3,572), Chinese (n = 1,823), Japanese (n = 951), Pacific Islanders (n = 593), and South Asians (n = 555), enrolled in the registry. We calculated incidence rates (means ± SD; 7.2 ± 3.3 years follow-up) and created Cox proportional hazards models adjusted for age, educational attainment, English proficiency, neighborhood deprivation, BMI, smoking, alcohol use, exercise, medication adherence, type and duration of diabetes, HbA1c, hypertension, estimated glomerular filtration rate, albuminuria, and LDL cholesterol. Incidence of myocardial infarction (MI), congestive heart failure, stroke, ESRD, and lower-extremity amputation (LEA) were age and sex adjusted.RESULTSPacific Islander women had the highest incidence of MI, whereas other ethnicities had significantly lower rates of MI than whites. Most nonwhite groups had higher rates of ESRD than whites. Asians had ~60% lower incidence of LEA compared with whites, African Americans, or Pacific Islanders. Incidence rates in Chinese, Japanese, and Filipinos were similar for most complications. For the three macrovascular complications, Pacific Islanders and South Asians had rates similar to whites.CONCLUSIONSIncidence of complications varied dramatically among the Asian subgroups and highlights the value of a more nuanced ethnic stratification for public health surveillance and etiologic research.

Renal function and cardiovascular risk markers in a remote Australian Aboriginal community.

Australian Aborigines living in remote areas have exceedingly high rates of renal failure together with increased cardiovascular morbidity and mortality. To examine the basis of this association, we studied markers of renal function and cardiovascular (CV) risk in a coastal Aboriginal community in a remote area of the Northern Territory of Australia. End-stage renal disease (ESRD) incidence rates in that community are 15 times the national non-Aboriginal rate and CV mortality rates in the region are increased 5-fold. A cross-sectional community survey was conducted. Markers of early renal disease examined included urine albumin/creatinine ratio (ACR), serum creatinine concentration and calculated glomerular filtration rate (GFR). CV risk markers included blood pressure as well as measures of glycaemia, diabetes and serum lipids. The study group included 237 people, 58% of the adult population of the community. The crude prevalence of microalbuminuria (urine ACR: 3.4-33.9 g/mol, 30-299 mg/g) was 31% and of overt albuminuria (urine ACR: >or=34 g/mol, >or=300 mg/g), 13%. The prevalence of overt albuminuria increased with age, but the prevalence of microalbuminuria was greatest in the 45-54 year age group. Microalbuminuria was associated with increasing body mass index, whereas overt albuminuria was associated with increasing glycated haemoglobin (HbA1c) and systolic blood pressure and a history of diabetes. The prevalence of elevated serum creatinine concentration (>or=120 micromol/l) was 10%. GFR (calculated using the MDRD equation) was <60 ml/min/1.73 m(2) in 12% and 60-79 ml/min/1.73 m(2) in a further 36% of the study population. Although many people with albuminuria had well preserved GFRs, mean GFR was lower in people with higher levels of albuminuria. The high prevalence of markers of renal disease in this community was consistent with their high rates of ESRD. The distribution of microalbuminuria suggested a 'cohort effect', representing a group who will progress to overt albuminuria. The powerful association of renal disease markers with CV risk factors confirms a strong link between renal and CV disease in the early, asymptomatic stages of each. Thus, pathologic albuminuria, in part, might be a manifestation of the metabolic/haemodynamic syndrome and both conditions might arise out of a common menu of risk factors. Hence, a single agenda of primary and secondary intervention may benefit both.

Risks and costs of end-stage renal disease after heart transplantation.

To estimate the risks and costs of end-stage renal disease (ESRD) after heart transplantation. Previous studies have shown high rates of ESRD among solid-organ transplant patients, but the relevance of these studies for current transplant practices and policies is unclear. Limitations of prior studies include relatively small, single-center samples and estimates made before implementing suggested practice changes to reduce ESRD risk. Medicare beneficiaries who underwent heart transplantation between 1989 and 1994 were eligible for study inclusion (n=2088). Thirty-four patients undergoing dialysis or who had the diagnosis of ESRD before or at transplantation were excluded from the study. ESRD was defined as any patient undergoing renal transplantation or requiring dialysis for more than 3 months. Mortality and ESRD events were recorded up to 1995. ESRD risk was estimated using the Kaplan-Meier product-limit estimator and logistic regression analyses. Linear regression was performed to determine expenditures for treating ESRD, and we developed long-term models of the risk and direct medical costs of ESRD care. The annual risk of ESRD was 0.37% in the first year after transplant and increased to 4.49% by the sixth posttransplant year. There was no significant trend in the risk of ESRD based on the year of transplantation, even after adjusting for patient characteristics. The average cumulative 10-year direct cost of ESRD per patient undergoing heart transplantation exceeded $13,000. In a large, national sample of patients undergoing heart transplantation, ESRD is not rare, even for patients undergoing transplant after the development of new practices intended to reduce its occurrence. ESRD remains an important component of the costs of heart transplantation.

Renal mortality associated with non-insulin-dependent diabetes mellitus

iabetic nephropathy is the most common D cause of end-stage renal disease in the United States. Patients with insulin-dependent diabetes mellitus (IDDM) have twice the chance of developing renal failure compared to those with non-insulin-dependent diabetes mellitus (NIDDM).l Since the prevalence of NIDDM is ten times that of IDDM, most of the patients that progress to endstage renal disease (ESRD) are those with NIDDM.’ It is estimated that greater than 3% of the nearly 300,000 patients on dialysis have diabetes as an etiology; 90% of these diabetics have NlDDM associated nephropathy.’ Since the prevalence of NIDDM is higher in certain ethnic groups, i.e., 59.5% for nonHispanic whites, 92.8% for Mexican-Americans, and 84.3% for African-Americans, it is associated with a higher rate of ESRD.2 This is exemplified by a greater than six fold higher incidence of ESRD in Mexicanand African-Americans compared to non-Hispanic whites.* The paper will provide a brief overview of factors that predispose patients with NIDDM to develop nephropathy. It will also discuss specific antihypertensive strategies that may provide additional benefit to these patients.

Fiberglass or silica exposure and increased nephritis or ESRD (end-stage renal disease).

The U.S. multiplant cohort mortality study of workers producing manufactured mineral fibers is finding increasing mortality from nephritis and/or nephrosis. We examine other data sets to see if similar effects can be identified. In a case-referent study among Michigan patients with end-stage renal disease (ESRD), men with exposures to silica have elevated odds ratio for ESRD. In a California occupational mortality study based on 1979-81 data, a number of the construction trades, farmers, and farm laborers show excess mortality for renal disease. The highest mortality ratio is found in the category including insulation workers. This ratio remains significantly elevated when adjusted for estimated exposures to smoking, alcohol, and for socio-economic status. California mortality data from 20 years earlier (1959-61) fail to show much excess renal disease in construction workers, but do for farmers. In Singapore, granite workers with a long-term exposure to silica have excess excretion of albumin and similar compounds compared to less exposed controls, leading to the presumption that silica exposure can lead to silica nephrotoxicity. Balkan nephropathy has been associated with consumption of well water high in silica. In the Negev of Israel, dust storms are a vehicle for increasing respiratory uptake of silica. The Beduin, thought to be a population with maximal exposures, have higher rates of ESRD than do Jews in the age groups over 60 years. Although high blood concentrations of silica are found in persons with renal failure, the close association with elevated creatinine has been interpreted as evidence that the buildup of silica is due to renal failure, rather than vice-versa.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparative Incidence Rates of End-Stage Renal Disease Treatment by State

End-stage renal disease (ESRD) treatment rates vary significantly between states in the United States. Much of this variation relates to the much higher rate of ESRD in blacks and the differences in race, age, and sex composition of various states. Even after adjusting for race, age, and sex differences utilizing data from new patients reported to Medicare with ESRD between 1980 and 1983, marked variation in treatment incidence rates per million population were still present. Overall rates varied from 45 in North Dakota to 99 in New Jersey. Regional rate patterns were demonstrated with very high rates in southwestern states (Texas, New Mexico, Arizona, and California: 87-91/million). In contrast, several south-central states had lower rates (Arkansas, Louisiana, Mississippi, Alabama, and Tennessee: 66-75/million). By state the rates for blacks were consistently higher than for whites. After adjustment for sex and age differences, the rates for blacks varied from 125 in Arkansas to 242 in New Jersey. Several north-eastern states (Massachusetts, Connecticut, Rhode Island, New Jersey) had higher rates of ESRD in blacks (197-242 million) as compared with several south-central states (Arkansas, Louisiana, Mississippi, Tennessee, Alabama) where rates varied from 125 to 180 million. ESRD rates by primary etiologies by state showed marked variation of the major primary etiologies of ESRD: diabetic nephropathy rates were most predictive of overall ESRD rates, with much higher rates in the southwestern states (28.1-33.2) as compared with the south-central states (12.8-16.3).(ABSTRACT TRUNCATED AT 250 WORDS)