Kidney Failure and the Federal Government (1991) / Chapter Skim
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The ESRD Patient Population: Special Groups
The ESRD Patient Population: Special Groups
Pages 85-109
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From page 85... ...
PEDIATRIC PATIENTS Pediatric ESRD patients, ranging in age from birth to 20 years, are special patients with very special needs. Their physical and emotional growth relative to their age is often delayed as a consequence of their chronic illness.
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From page 86... ...
These include growth retardation, delayed pubertal development, transfusion-dependent anemia, bone and necrologic abnormalities, as well as psychosocial and educational problems. The burdens common to all ESRD patients are often greater for pediatric patients.
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From page 87... ...
TABLE 5-2 Percentage of Pediatric End-Stage Renal Disease (ESRD) Patients with Functioning Graft, 1978 and 1987 Age Group (years)
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From page 88... ...
at One Year by Year of Incidence and Age Group, 1978 and 1987 Age Group (years) ~ 978 ~ 987 Under 1 a 83.9 1-4 76.0 98.5 5-9 93.8 99.1 10-14 96.7 99.0 15-19 95.5 96.5 NOTE: Includes dialysis and transplant patients who have survived the first 90 days of end-stage renal disease (ESRD)
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From page 89... ...
There is a shortage, however, of trained personnel to deal with pediatric ESRD patients (Fine, 19901. Specialized pediatric renal failure centers are necessary for the training of the nephrologists, nutritionists, social workers, and nursing personnel.
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From page 90... ...
The primary diagnoses leading to renal failure among treated elderly ESRD patients have changed over time (IOM, 1990~. Diabetes and hypertension have accounted for an increasing proportion of cases.
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From page 91... ...
Most reports indicate stable adjusted mortality rates since the mid1980s (Eggers, 1990; Sehgal et al., 1990; USRDS, 19901. A stable mortality despite an increasing proportion of very elderly and of underlying conditions such as diabetes among the elderly patients may reflect increasing physician and provider experience over time in treating a more vulnerable patient population.
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From page 92... ...
In the 1970s, diabetic patients were a small proportion of total ESRD patients (Table 5-51. By 1983, however, diabetic kidney disease had become the most frequent diagnosis among patients entering the Medicare ESRD program.
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From page 93... ...
constitute only 5 to 10 percent of all diabetics, they account for 40 percent or more of renal failure due to diabetes (Hawthorne, 1990; Rettig and Teutsch, 1990~. The relative risk of renal failure appears to be 10 to 15 times greater from IDDM than from non-insulin-dependent diabetes mellitus (NIDDM)
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From page 94... ...
Hypertension is an important predictor and possible cause of diabetic nephropathy. The appearance of hypertension in a diabetic patient with previously normal blood pressure may be the first sign of renal disease (Selby et al., 1990~.
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From page 95... ...
HYPERTENSIVE PATIENTS The incidence and prevalence of treated hypertensive ESRD has increased continually since the Medicare ESRD program was initiated. In 1974, 13.5 percent of the new patients (less than 1,000)
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From page 96... ...
In people with mild to moderate hypertension, however, little information exists about the risk of renal failure and how that risk is affected by various treatments (Whelton and Klag, 1989~. Although hypertension is a cause of renal failure, renal disease also causes hypertension.
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From page 97... ...
Both the absolute numbers and the proportion of ESRD patients attributed to hypertension have increased substantially over the past two decades. The increase of hypertensive ESRD results, in part, from decreased mortality from competing illnesses, such as coronary heart disease and stroke, attributable to improved treatment of hypertension.
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From page 98... ...
There were 15 deaths attributed to renal disease in the treatment group and 10 in the control group after 5 years (Shulman et al., 19891. Mortality is a poor marker of treatment efficacy, however, since most treated ESRD patients die from causes other than renal disease.
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From page 99... ...
For the three diastolic blood pressure groups 90-104 mmHg, 105-114 mmHg, and greater than 115 mmHg, he calculated approximately 320,000, 80,000, and 47,000 new cases, respectively. According to his calculations, two-thirds of these new renal disease cases were expected in hypertensive patients with lowest blood pressure (DBP 90-104 mmHg)
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From page 100... ...
Between 1981 and 1988, the average yearly rates of increase in new Medicare ESRD patients among Native Americans and Asians/Pacific Islanders were 16.6 percent and 26.2 percent, respectively.3 Estimated average yearly rate of increase for Hispanics, based on a sample of 9,690 Medicare patients with Hispanic surnames, was 12.7 percent (IOM, 19901. Age- and sex-adjusted treated ESRD incidence rates are four times greater for blacks and Native Americans (404 and 109 per million population in 1988, respectively)
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From page 101... ...
Diabetes accounted for 50 percent of new patients, and the incidence rate of diabetic ESRD was 9.6 times that of whites. The Pima Indians of south central Arizona have one of the world's highest incidence rates of NIDDM, with an age- and gender-adjusted rate of 27 per 1,000 population, approximately 19 times the rate among whites (Knowler et al., 1978; Rate et al., 1983~.
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From page 102... ...
, diabetes is the primary diagnosis leading to ESRD. This high rate of diabetic ESRD is partly explained by the increased prevalence of diabetes mellitus: NIDDM is estimated to be about three times greater among Mexican Americans than among non-Hispanic whites (Stern et al., 1984~.
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From page 103... ...
Among transplant patients, black patients have lower survival than whites and other nonwhites. Between 1981 and 1983, the overall age-adjusted mortality rate from renal failure for Native Americans was 2.6 times the corresponding rate for all Americans.
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From page 104... ...
population (Indian Health Service, 1987~. These extreme mortality rates seem to correlate best with the incidence of ESRD secondary to diabetes mellitus, recorded as high as 89 percent of incident cases in the Aberdeen area and 95 percent in the Pima tribe (Nelson et al., 19881.
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From page 105... ...
Although these data do not control for possible influences on allograft survival, such as HLA matching and age, gender, and race of organ donor, studies that control for these potentially confounding factors have, for the most part, shown similar shortened allograft survival in black recipients (Orial et al., 1982; Krakauer et al., 1983; USRDS, 1990~. There are exceptions, including Michigan (Weller et al., 1985)
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From page 106... ...
. However, the ESRD patient population has not been systematically studied in SES terms and existing data do not permit a direct examination of relation of SES to renal failure.
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From page 107... ...
1990. Mortality rates among dialysis patients in Medicare's End-Stage Renal Disease Program.
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From page 108... ...
1990. The incidence of end-stage renal disease in type I and type II diabetes mellitus.
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From page 109... ...
1991. Does racial variation in risk factors explain black-white differences in the incidence of hypertensive end-stage renal disease?
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