US Dialysis Patients Research Articles

Sudden Cardiac Death Reporting in US Dialysis Patients: Comparison of USRDS and National Death Index Data.

Cause-specific mortality data from the United States Renal Data System (USRDS) form the basis for identifying cardiovascular disease (CVD), specifically sudden cardiac death (SCD), as the leading cause of death for patients on dialysis. Death certificate data from the National Death Index (NDI) is the epidemiological standard for assessing causes of death for the United States population. The cause of death has not been compared between the USRDS and the NDI. Among 39,507 adults starting dialysis in the US, we identified 6436 patients who died between 2003-2009. We classified the cause of death as SCD, non-SCD CVD, cancer, infection, and others; and compared the USRDS to the NDI. Median age at the time of death was 70 years, 44% were female, and 30% were non-Hispanic Black individuals. The median time from dialysis initiation to death was 1.2 years. Most deaths occurred in-hospital (N=4681, 73%). The overall concordance in cause of death between the two national registries was 42% (κ=0.23, 95% confidence interval 0.22 to 0.24). CVD, including SCD and non-SCD CVD, accounted for 67% of deaths per the USRDS but only 52% per the NDI; this difference was mainly driven by the larger proportion of SCD in the USRDS (42%) versus the NDI (22%). Of the 2962 deaths reported as SCD by the USRDS, only 35% were also classified as SCD by the NDI. Out-of-hospital deaths were more likely to be classified as SCD in the USRDS (60%) versus the NDI (29%), compared to in-hospital deaths (41% in the USRDS; 25% in the NDI). Significant discordance exists in the causes of death for patients on dialysis reported by the USRDS and the NDI. Our findings underscore the urgent need to integrate NDI data into the USRDS registry and enhance the accuracy of cause-of-death reporting.

Decline in Opioid Prescriptions in US Dialysis and Kidney Transplant Patients, 2011-2020

Decline in Opioid Prescriptions in US Dialysis and Kidney Transplant Patients, 2011-2020

COVID-19 mortality among kidney transplant candidates is strongly associated with social determinants of health.

The COVID‐19 pandemic has affected all portions of the global population. However, many factors have been shown to be particularly associated with COVID‐19 mortality including demographic characteristics, behavior, comorbidities, and social conditions. Kidney transplant candidates may be particularly vulnerable to COVID‐19 as many are dialysis‐dependent and have comorbid conditions. We examined factors associated with COVID‐19 mortality among kidney transplant candidates from the National Scientific Registry of Transplant Recipients from March 1 to December 1, 2020. We evaluated crude rates and multivariable incident rate ratios (IRR) of COVID‐19 mortality. There were 131 659 candidates during the study period with 3534 all‐cause deaths and 384 denoted a COVID‐19 cause (5.00/1000 person years). Factors associated with increased COVID‐19 mortality included increased age, males, higher body mass index, and diabetes. In addition, Blacks (IRR = 1.96, 95% C.I.: 1.43–2.69) and Hispanics (IRR = 3.38, 95% C.I.: 2.46–4.66) had higher COVID‐19 mortality relative to Whites. Patients with lower educational attainment, high school or less (IRR = 1.93, 95% C.I.: 1.19–3.12, relative to post‐graduate), Medicaid insurance (IRR = 1.73, 95% C.I.: 1.26–2.39, relative to private), residence in most distressed neighborhoods (fifth quintile IRR = 1.93, 95% C.I.: 1.28–2.90, relative to first quintile), and most urban and most rural had higher adjusted rates of COVID‐19 mortality. Among kidney transplant candidates in the United States, social determinants of health in addition to demographic and clinical factors are significantly associated with COVID‐19 mortality.

COVID-19 Among US Dialysis Patients: Risk Factors and Outcomes From a National Dialysis Provider

Rationale & ObjectiveDuring the coronavirus disease 2019 (COVID-19) pandemic, patients receiving maintenance dialysis are a highly vulnerable population due to their comorbidities and circumstances that limit physical distancing during treatment. This study sought to characterize the risk factors for and outcomes following COVID-19 in this population.Study DesignRetrospective cohort study.Setting & ParticipantsMaintenance dialysis patients in clinics of a midsize national dialysis provider that had at least 1 patient who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from February to June 2020.PredictorsDemographics, dialysis characteristics, residence in a congregated setting, comorbid conditions, measurements of frailty, and use of selected medications.OutcomesCOVID-19, defined as having a positive SARS-CoV-2 test result, and all-cause mortality among those with COVID-19.Analytical ApproachLogistic regression analyses conducted to identify clinical characteristics associated with COVID-19 and risk factors associated with mortality among patients following COVID-19.Results438 of 7948 (5.5%) maintenance dialysis patients developed COVID-19. Male sex, Black race, in-center dialysis (vs home dialysis), treatment at an urban clinic, residence in a congregate setting, and greater comorbidity were associated with contracting COVID-19. Odds of COVID-19 were 17-fold higher for those residing in a congregated setting (odds ratio [OR], 17.10 [95% CI, 13.51-21.54]). Of the 438 maintenance dialysis patients with COVID-19, 109 (24.9%) died. Older age, heart disease, and markers of frailty were associated with mortality.LimitationsNo distinction was detected between symptomatic and asymptomatic SARS-CoV-2 positivity, with asymptomatic screening limited by testing capacity during this initial COVID-19 surge period.ConclusionsCOVID-19 is common among patients receiving maintenance dialysis, particularly those residing in congregate settings. Among maintenance dialysis patients with COVID-19, mortality is high, exceeding 20%.

Incidence and risk factors for HPV-associated cancers in women with end-stage renal disease

Human papillomavirus (HPV) causes the majority of cervical, anal/rectal, and oropharyngeal cancers in women. End-stage renal disease (ESRD) is also associated with an increased risk of malignancy, but the incidence...

Concomitant Use of Gabapentinoids with Opioids Is Associated with Increased Mortality and Morbidity among Dialysis Patients

Background: The opioid epidemic is a public health emergency and appropriate medication prescription for pain remains challenging. Physicians have increasingly prescribed gabapentinoids for pain despite limited evidence supporting their use. We determined the prevalence of concomitant gabapentinoid and opioid prescriptions and evaluated their associations with outcomes among dialysis patients. Methods: We used the United States Renal Data System to identify patients treated with dialysis with Part A, B, and D coverage for all of 2010. Patients were grouped into 4 categories of drugs exposure status in 2010: (1) no prescriptions of either an opioid or gabapentinoid, (2) ≥1 prescription of an opioid and no prescriptions of gabapentinoids, (3) no prescriptions of an opioid and ≥1 prescription of gabapenbtinoids, (4) ≥1 prescription of both an opioid and gabapentinoid. Outcomes included 2-year all-cause death, dialysis discontinuation, and hospitalizations assessed in 2011 and 2012. Results: The study population included 153,758 dialysis patients. Concomitant prescription of an opioid and gabapentin (15%) was more common than concomitant prescription of an opioid and pregabalin (4%). In adjusted analyses, concomitant prescription of an opioid and gabapentin compared to no prescription of either was associated with increased risk of death (hazard ratio [HR] 1.16, 95% CI 1.12–1.19), dialysis discontinuation (HR 1.14, 95% CI 1.03–1.27), and hospitalization (HR 1.33, 95% CI 1.31–1.36). Concomitant prescription of an opioid and pregabalin compared to no prescription of either was associated with increased mortality (HR 1.22, 95% CI 1.16–1.28) and hospitalization (HR 1.37, 95% CI 1.33–1.41), but not dialysis discontinuation (HR 1.13, 95% CI 0.95–1.35). Prescription of opioids and gabepentinoids compared to only being prescribed opioids was associated with higher risk of hospitalizations, but not mortality, or dialysis discontinuation. Conclusions: Concomitant prescription of opioids and gabapentinoids among US dialysis patients is common, and both drugs have independent effects on outcomes. Future research should prospectively investigate the potential harms of such drugs and identify safer alternatives for treatment of pain in end-stage renal disease patients.

Paying for Frequent Dialysis

In late 2017, the 7 regional contractors responsible for paying dialysis claims in Medicare proposed new payment rules that would restrict payment for hemodialysis treatments in excess of 3 weekly to exceptional acute-care circumstances. Frequent hemodialysis is performed more frequently than the traditional thrice-weekly pattern, and many stakeholders-patients, providers, dialysis machine manufacturers, and others-have expressed concern that these payment rules will inhibit the growth of this treatment modality's use among US dialysis patients. In this Perspective, we explain the role of these contractors in the context of Medicare's in-center hemodialysis-centric dialysis payment system and assess how well this system accommodates the higher treatment frequencies of both peritoneal dialysis and frequent hemodialysis. Then, given the available evidence concerning the relative effectiveness of these modalities versus thrice-weekly in-center hemodialysis and trends in their use, we discuss options for modifying Medicare's payment system to support frequent dialysis.

Regional and Temporal Variations in Comorbidity Among US Dialysis Patients: A Longitudinal Study of Medicare Claims Data.

Medicare claims data are commonly used to query comorbidities for case-mix adjustment in research of patients with end-stage renal disease (ESRD) in the United States. These adjustments may affect reimbursement and quality rating through comparative profiling and ranking of dialysis facilities. We studied regional and temporal variations in comorbidity from claims data in the United States Renal Data System. Patients with a previous 1-year Medicare history who initiated dialysis therapy between 2006 and 2009 were examined with a follow-up period until 2012. By linking pre- and post-ESRD Medicare claims with the Dartmouth Atlas, we carried out a longitudinal data analysis with multivariable adjustment to investigate regional and temporal variations in the Liu comorbidity index. We identified 23 336 incident hemodialysis patients who were covered by Medicare the year prior to dialysis initiation and had survived with complete 3 years of follow-up data. With the United States divided into 4 geographic regions, the Western region was found to have the lowest Liu index over all 3 follow-up years, compared with the respective years in the other regions (Midwest, Northeast, and South). In comparison with the first year, the Liu index dropped significantly during the second and third years of follow-up across all 4 regions. Significant regional and temporal variations observed in the comorbidity index cannot be explained by differences in reimbursement (average per state) or predialysis comorbidity. Based on our exploratory study, future studies should focus on identifying the factors and reasons for these variations which have the potential to affect health care policy and research.

Phosphate-Binder Use in US Dialysis Patients: Prevalence, Costs, Evidence, and Policies

Medicare costs for phosphate binders for US dialysis patients and patients with chronic kidney disease enrolled in Medicare Part D exceeded $1.5 billion in 2015. Previous data have shown that Part D costs for mineral and bone disorder medications increased faster than costs for all Part D medications for dialysis patients. Despite extensive use of phosphate binders and escalating costs, conclusive evidence is lacking that they improve important clinical end points in dialysis patients or non-dialysis-dependent patients with chronic kidney disease. Using dialysis patient data from the US Renal Data System and laboratory information from the Centers for Medicare & Medicaid Services (CMS) CROWNWeb data, we update information on trends in phosphate-binder use, calcium and phosphorus values, and costs for Medicare-covered dialysis patients. We discuss these results in the context of evidence from clinical trials, meta-analyses, and observational studies evaluating phosphate-binder efficacy, safety, comparative effectiveness, and cost-effectiveness. Based on our analysis, we note a need for US Food and Drug Administration guidance regarding clinical evaluation of new phosphate binders, and we suggest that it would be in CMS' best interest to fund a clinical trial to assess whether lower versus higher phosphate concentrations improve hard clinical outcomes, and if so, whether particular phosphate binders are superior to placebo or other binders in improving these outcomes.

Measuring patient experience in dialysis: a new paradigm of quality assessment.

Patients' experience of care (PEC) is as an important dimension in quality of care. As a distinct entity from patient satisfaction and patient health-related quality of life, PEC is defined as patients' perceptions of the range of interactions they have with the health care system, including care from providers, facilities, and health plans. While traditionally PEC may be ascertained via informal assessments, in recent years, especially in the United States, there has been a shift towards standardized surveillance of PEC amongst dialysis patients in order to: (1) set a normative expectation regarding the importance of PEC; (2) standardize the components of patients' experience that are assessed to minimize potential "blind spots"; (3) provide a direct "voice" to the patient in communicating perceptions of their care; (4) facilitate comparisons of quality across facilities; and (5) broaden accountability for PEC to the entire multidisciplinary dialysis care team. In this review, we will discuss the significance of PEC as a quality of care metric in dialysis patients; the history of PEC assessment across other health care arenas; the development of the In-Center Hemodialysis Consumer Assessment of Healthcare Provider and Systems survey as a means to standardize PEC assessment among US dialysis patients; experiences in PEC assessment across international dialysis populations; and future areas of research needed to refine the ascertainment of PEC and its impact upon patient outcomes.

Clinical factors influencing the decision to order red blood cell transfusions for a sample of US dialysis patients .

To characterize the clinical context for the decision to order red blood cell (RBC) transfusions in dialysis patients. Retrospective review of medical records from three integrated health systems serving chronic dialysis patients. Subjects were randomly selected from all patients who received at least one transfusion between January 2009 and December 2013. Data abstracted included transfusion setting, prescribing clinician type, patient demographics and hemoglobin (Hb) concentration prior to transfusion, and cataloguing and prioritizing of clinical factors for their contribution to the decision to transfuse. Data from one system were stratified between transfusions before and after the 2011 dialysis payment reform and anemia drug label changes. Charts for 590 patients were reviewed. The primary reason for transfusion was low Hb (51%), medical conditions (22%), symptoms of anemia (18%), surgery-related (6%), and undetermined (3%). In 93% of cases, multiple factors were cited as contributors to the transfusion decision. Mean Hb prior to transfusion was 7.2 g/dL in patients where low Hb was the primary reason for transfusion (range: 4.0-9.9 g/dL). The decision to transfuse dialysis patients is influenced by multiple patient factors and medical conditions, of which low Hb is the main contributor to this decision about half of the time. .

Younger black patients have a higher risk of infection mortality that is mostly non-dialysis related: A national study of cause-specific mortality among U.S. maintenance dialysis patients.

While it has been well documented that in the U.S., black and Hispanic dialysis patients have overall lower risks of death than white dialysis patients, little is known whether their lower risks are observed in cause-specific deaths. Additionally, recent research reported that younger black patients have a higher risk of death, but the source is unclear. Therefore, this study examined cause-specific deaths among US dialysis patients by race/ethnicity and age. This national study included 1,255,640 incident dialysis patients between 1995 and 2010 in the United States Renal Data System. Five cause-specific mortality rates, including cardiovascular (CVD), infection, malignancy, other known causes (miscellaneous), and unknown, were compared across blacks, Hispanics, and whites overall and stratified by age groups. After multiple adjustments, Hispanic patients had the lowest risk of mortality for every major cause in almost all ages. Compared with whites, blacks had a lower risk of death from CVD, malignancy and miscellaneous causes in most age groups, but not from infection. In fact, blacks had a higher risk of infection death than whites in ages 18-30 years (HR [95% CI] 1.94 [1.69-2.23]; P < 0.001), 31-40 years (HR 1.51 [1.40-1.63]; P < 0.001) and 41-50 years (HR 1.07 [1.02-1.12]; P = 0.009), which were partially attributed to their higher prevalence of AIDS nephropathy. For each race/ethnicity, more than two-thirds of infection deaths were due to non-dialysis related infections. Hispanics had the lowest risk for each major cause of death. Blacks were less likely to die than whites from most causes, except infection. The previously reported higher overall mortality rate for younger blacks is attributed to their two-fold higher infection mortality, which is mostly non-dialysis related, suggesting a new direction to improve their overall health status. Research is greatly needed to determine social and biological factors that account for the survival gap in dialysis among different racial/ethnic groups.

The Relationship Between Ultraviolet Light Exposure and Mortality in Dialysis Patients

Background: Emerging data suggest that reduced exposure to ultraviolet (UV) radiation is associated with increased mortality in the general population. To date, the association between UV exposure and mortality in dialysis patients has not been examined. Methods: We examined the association between UV index, a proxy of UV exposure, and all-cause mortality among 47,286 US dialysis patients (entry period 2001-2006, with follow-up through 2009) from a large national dialysis organization using multivariable Cox regression. The UV index was ascertained by linking individual patients' residential zip codes to National Oceanic and Atmospheric Administration data, and was categorized as low (0-<3), moderate (3-<5), moderate-high (5-<6), high (6-<7), and very-high (≥7). In secondary analyses, we examined the UV index-mortality association within subgroups of age (<65 vs. ≥65 years old), sex, and race (white vs. non-white). Results: The study population's mean ± SD age was 60 ± 16 and included 46% women and 56% diabetics. Compared to patients residing in moderate-high UV index regions, those residing in high and very-high UV index regions had a lower mortality risk: adjusted HRs 0.84 (95% CI) 0.81-0.88 and 0.83 (95% CI) 0.75-0.91, respectively. A similar inverse association between UV index and mortality was observed across all subgroups, although there was more pronounced reduction in mortality among whites vs. non-whites. Conclusion: These data suggest that dialysis patients residing in higher UV index regions have lower all-cause mortality compared to those living in moderate-high UV regions. Further studies are needed to determine the mechanisms underlying the UV index-mortality association.

Relationship Between Zip Code Racial Composition and Kidney Transplantation Practices.

Background: A disproportionately large number of black US dialysis patients live in zip codes where most other residents are black. Little is known about practices and outcomes after kidney transplant in patients living in these predominantly black residential areas. Methods: Using data from the United States Renal Data System (USRDS), we identified 69,319 patients who were either black or white and received their first kidney transplant between 1/1/2000 and 9/30/2005. We compared recipient, donor and procedure characteristics and patient and graft survival after transplant among patients living in predominantly black ( ≥50% black residents) vs. other (<50% black residents) zip codes. Results: Forty-one percent of black (n=7,257) and 2% of white (n=972) cohort members lived in a predominantly black zip code (n=938, 5.6% of zip codes). Blacks had a lower rate of living donors compared to whites (26% vs. 45%). Adjusted analyses (table) demonstrated that recipients living in predominantly black vs. other zip codes had a 15% higher risk of receiving deceased donor transplant, 21% higher rate of being on HD vs. PD prior to transplant, 13% higher chance of being on dialysis for 2 years prior to transplant, 20% lower chance of receiving a zero mismatch kidney and 19% receiving a preemptive transplant. Adjusted association racial composition on kidney transplant characteristics.Table: No Caption available.*Relative risk for patients living in zip codes with ≥50% vs. <50% black residents (95% confidence interval) ** gender of recipient, age at transplant, donor type, dialysis modality pretx, time on dialysis, premptive tx vs.not, donor race, donor BMI, recipient comorbidities including BMI, presence of diabetes, CVD and cause of ESRD, education, employement, transplant center effect. Conclusions: Blacks segregate to black neighborhoods. Living in predominantly black neighborhoods has an adverse impact on treatment practices related to kidney transplant.

The DOPPS Practice Monitor for US Dialysis Care: Potential Impact of Recent Guidelines and Regulatory Changes on Management of Mineral and Bone Disorder Among US Hemodialysis Patients

The DOPPS Practice Monitor for US Dialysis Care: Potential Impact of Recent Guidelines and Regulatory Changes on Management of Mineral and Bone Disorder Among US Hemodialysis Patients

TSAT is a better predictor than ferritin of hemoglobin response to Epoetin alfa in US dialysis patients.

Clinical guidelines recommend concurrent treatment of anemia in end-stage renal disease with erythropoiesis-stimulating agents (ESAs) and iron. However, there are mixed data about optimal iron supplementation. To help address this gap, the relationship between iron markers and hemoglobin (Hb) response to ESA (Epoetin alfa) dose was examined. Electronic medical records of 1902 US chronic hemodialysis patients were analyzed over a 12-month period between June 2009 and June 2010. The analysis included patients who had at least one Hb value during each 4-week interval for four consecutive intervals (k − 2, k − 1, k, and k + 1; k is the index interval), received at least one ESA dose during intervals k − 1 or k, had at least one transferrin saturation (TSAT) value at interval k, and at least one ferritin value during intervals k − 2, k − 1, or k. Effect modification by TSAT and ferritin on Hb response was evaluated using the generalized estimating equations approach. Patients had a mean (standard deviation) age of 62 (15) years; 41% were Caucasian, 34% African American, 65% had hypertension, and 39% diabetes. Transferrin saturation, but not ferritin, had a statistically significant (P < 0.05) modifying effect on Hb response. Maximum Hb response was achieved when TSAT was 34%, with minimal incremental effect beyond these levels. Of the two standard clinical iron markers, TSAT should be used as the primary marker of the modifying effect of iron on Hb response to ESA. Long-term safety of iron use to improve Hb response to ESA warrants further study.

Invasive Methicillin-Resistant Staphylococcus aureus Infections Among Patients on Chronic Dialysis in the United States, 2005-2011

Approximately 15 700 invasive methicillin-resistant Staphylococcus aureus (MRSA) infections occurred in US dialysis patients in 2010. Frequent hospital visits and prolonged bloodstream access, especially via central venous catheters (CVCs), are risk factors among hemodialysis patients. We describe the epidemiology of and recent trends in invasive MRSA infections among dialysis patients. We analyzed population-based data from 9 US metropolitan areas from 2005 to 2011. Cases were defined as MRSA isolated from a normally sterile body site in a surveillance area resident who received dialysis, and were classified as hospital-onset (HO; culture collected >3 days after hospital admission) or healthcare-associated community-onset (HACO; all others). Incidence was calculated using denominators from the US Renal Data System. Temporal trends in incidence and national estimates were calculated controlling for age, sex, and race. From 2005 to 2011, 7489 cases were identified; 85.7% were HACO infections, and 93.2% were bloodstream infections. Incidence of invasive MRSA infections decreased from 6.5 to 4.2 per 100 dialysis patients (annual decrease, 7.3%) with annual decreases of 6.7% for HACO and 10.5% for HO cases. Among cases identified during 2009-2011, 70% of patients were hospitalized in the year prior to infection. Among hemodialysis cases, 60.4% of patients were dialyzed through a CVC. The 2011 national estimated number of MRSA infections was 15 169. There has been a substantial decrease in invasive MRSA infection incidence among dialysis patients. Most cases had previous hospitalizations, suggesting that efforts to control MRSA in hospitals might have contributed to the declines. Infection prevention measures should include improved vascular access and CVC care.

Influence of safety warnings on ESA prescribing among dialysis patients using an interrupted time series

BackgroundIn March, 2007, a black box warning was issued by the Food and Drug Administration (FDA) to use the lowest possible erythropoiesis-stimulating agents (ESA) doses for treatment of anemia associated with renal disease. The goal is to determine if a change in ESA use was observed following the warning among US dialysis patients.MethodsESA therapy was examined from September 2004 through August 2009 (thirty months before and after the FDA black box warning) among adult Medicare hemodialysis patients. An interrupted time series model assessed the impact of the warnings.ResultsThe FDA black box warning did not appear to influence ESA prescribing among the overall dialysis population. However, significant declines in ESA therapy after the FDA warnings were observed for selected populations. Patients with a hematocrit ≥36% had a declining month-to-month trend before (−164 units/week, p = <0.0001) and after the warnings (−80 units/week, p = .001), and a large drop in ESA level immediately after the black box (−4,744 units/week, p = <.0001). Not-for-profit facilities had a declining month-to-month trend before the warnings (−90 units/week, p = .009) and a large drop in ESA dose immediately afterwards (−2,487 units/week, p = 0.015). In contrast, for-profit facilities did not have a significant change in ESA prescribing.ConclusionsESA therapy had been both profitable for providers and controversial regarding benefits for nearly two decades. The extent to which a FDA black box warning highlighting important safety concerns influenced use of ESA therapy among nephrologists and dialysis providers was unknown. Our study found no evidence of changes in ESA prescribing for the overall dialysis population resulting from a FDA black box warning.

Declining Mortality Rates despite Increases in Clinical Coronary Artery Disease among US Dialysis Patients: A National Registry Study

Background/Aims: Coronary artery disease (CAD) is a major risk factor for death on dialysis. The objective of this study was to compare prevalent trends and patterns of survival in successive national cohorts. Methods: National data on 823,753 incident dialysis patients, aged 18 and over, were analyzed from the US Renal Data System from 1995 to 2004. The prevalence of CAD was compared across calendar years by sex and race categorized as; White, Black, Asian and Native American/Alaskan Native (Native Am). Two-year mortality rates were determined for annual cohorts and multivariable Cox regression compared hazard ratios (HR) and 95% confidence intervals. Results: From 1995 to 2004, the annual prevalence of CAD increased significantly in men from 25.2 to 30.1% and in women from 22.1 to 25.3%, p < 0.001. For men, the rise in prevalence was largely due to increases among Black men and older White men. For women, the pattern was similar. During this period, death rates decreased significantly from 379 to 348 and from 396 to 357 per 1,000 person-years in men and women respectively. Multivariate analysis identified significant reductions in mortality with advancing calendar year for White (HR 0.98 (0.98-0.99)), Asian (HR 0.93 (0.91-0.96)), and Native Am men (HR 0.95 (0.90-0.99)), and for White (HR 0.99 (0.98-0.99)) and Native Am women (HR 0.93 (0.89-0.98)). No significant trends were observed for Black patients. Conclusions: Despite a rising burden of CAD among incident US dialysis patients, mortality rates have fallen for most groups. Substantial racial disparities remain.

Trends in Hip Fracture Rates in US Hemodialysis Patients, 1993-2010

Changes in mineral and bone disorder treatment patterns and demographic changes in the dialysis population may have influenced hip fracture rates in US dialysis patients in 1993-2010. Retrospective follow-up study analyzing trends over time in hospitalized hip fracture rates. Using Medicare data, we created 2 point-prevalent study cohorts for each study year. Hemodialysis cohorts included patients with Medicare as primary payer receiving hemodialysis in the United States on January 1 of each year; non-end-stage renal disease (ESRD) cohorts included Medicare beneficiaries 66 years or older on January 1 of each year. Age, sex, race, primary cause of ESRD, dual Medicare/Medicaid enrollment status, comorbid conditions. Hip fracture rates. Unadjusted hip fracture rates measured using number of events per 1,000 person-years in each year, then adjusted for patient characteristics. Poisson models estimated strata-specific event rates. The observed number of first hospitalized hip fracture events and the adjusted hip fracture rate increased steadily from 1993 (831 events; 11.9/1,000 person-years), peaked in 2004 (3,256 events; 21.9/1,000 person-years), and decreased through 2010 (2,912 events; 16.6/1,000 person-years). The trend for the subset of hemodialysis patients 66 years or older was similar to the trend for the full hemodialysis cohort; however, it differed markedly in magnitude and pattern from the non-ESRD Medicare cohort, for which rates were substantially lower and slowly decreasing since 1996. Unable to provide causal explanations for observed changes; hip fractures identified through inpatient episodes; results do not describe hemodialysis patients without Medicare Parts A and B; laboratory values unavailable in the Medicare data set. Temporal trends in hip fracture rates among Medicare hemodialysis patients differ markedly from the steadily decreasing trend in non-ESRD Medicare beneficiaries, showing a relatively rapid increase until 2004 and relatively rapid decrease thereafter. Further research is needed to define associated factors.