AAll s well that ends well; still the fine s the crown; Whate er the course, the end is the renown. WILLIAM SHAKESPEARE, All s Well That Ends Well mthree TrEATMENT MODALITIES
7 ž 21 ATLAS OF ESRD IN THE UNITED STATES HemodiAlysis The prevalent hemodialysis and transplant populations have seen the greatest growth since 199, while the number of patients on peritoneal dialysis has continued to fall since its peak in 1996 (fig 3.1). The decline in this latter population appears to coincide with the publication of studies showing adverse outcomes on peritoneal dialysis compared to hemodialysis (Bloembergen 1995). More recent studies, however, have shown that the two therapies are more difficult to compare than previously thought, and that certain patient populations fare better on one modality then on the other (Fenton 1997, Collins 1999, Vonesh 1999). Readers are referred to the literature for a more complete discussion of these issues. Figures 3.2 and 3.3 illustrate modality use by ESRD network and state. The use of peritoneal dialysis, for example, is as low as 5% in Network 4 and as high as 11% in Network 12. The geographic distribution of the modalities (figs 3.5 7) shows patterns that are most likely the result of incident rates, survival rates, and, for transplant patients, the combination of organ availability and graft survival. For hemodialysis there is a 51% difference between areas of the country with the lowest percent of patients on the modality (the Midwest and upper northwest) and areas with the highest (the southern and eastern coasts). Areas of higher peritoneal dialysis use, in contrast, are scattered across the country, and these areas have more than three times the percent of patients on PD as the areas in which it is not as common. Areas with the greatest percentage of patients transplanted are the upper northeast, the Upper Midwest, the western states, and Alaska. 25, 2, 15, 1, 5, 199 1991 1992 1993 Long-term survival with ESRD is highly associated with modality (fig 3.13). Among patients who have had ESRD for six years or longer, increasing numbers are treated with renal transplantation. Of the dialytic therapies, hemodialysis is associated with the best outcome, while peritoneal dialysis is associated with the fewest longterm survivors. Any comparisons between the dialysis modalities should recognize that there are more long-term options for therapy and access type for hemodialysis patients than for patients on peritoneal dialysis. Figure 3.2 Percent of patients on peritoneal dialysis, by network patients, 1997 1999 combined ESRD Networks 9 (Indiana, Kentucky, Ohio), 3 (New Jersey, Puerto Rico, Virgin Islands), and 12 (Iowa, Kansas, Missouri, Nebraska) have the highest proportion of patients on peritoneal dialysis. 1994 1995 Network 4 Network 14 Network 7 Network 1 Network 8 Network 2 Network 13 Networks 17/18 Network 5 Network 15 Network 11 TrAnsplAnt PeritoneAl dialysis 1996 1997 1998 1999 Figure 3.1 counts, by modality The total number of hemodialysis and transplant patients continues to rise, with the number of functioning transplant patients eclipsing 1, in 1999. Network 6 Network 16 Network 1 Network 9 Network 3 Network 12 2 4 6 8 1 12 Percent
CHAPTER 3 ž TREATMENT MODALITIES ž 71 HD PD TX AlAskA IdAHo NortH DAkotA Connecticut NebrAskA Wyoming IowA Vermont West VirginiA KAnsAs MinnesotA Wisconsin ArkAnsAs New HAmpsHire UtAH Oregon MicHigAn OHio Missouri OklAHomA IndiAnA WAsHington SoutH DAkotA MontAnA AlAbAmA Illinois MAssAcHusetts Mississippi New Mexico Tennessee MAine VirginiA New Jersey MArylAnd SoutH CArolinA HAwAii Kentucky ArizonA GeorgiA NortH CArolinA DelAwAre ColorAdo NevAdA New York CAliforniA PennsylvAniA FloridA RHode IslAnd TexAs LouisianA DC 2 4 6 8 1 Percent of patients Included in this chapter Figure 3.3 Percent of ESRD patients on initial modality, by state incident patients, 1999 The highest proportions of patients who begin ESRD therapy on peritoneal dialysis occur in Alaska, Connecticut, Idaho, and Nebraska, while patients in Minnesota, North Dakota, and Utah are the most likely to begin therapy with a transplant. Hemodialysis is used to the greatest extent in Alabama, Washington D.C., Louisiana, and Texas. Graphs, a table, and maps of the distribution of prevalent patients by modality Graphs of median age and modality by network Graphs of modality by time on ESRD, and a graph of the relative risk of changing modalities Maps of the odds of being on each modality, by race A graph of total years of ESRD, by modality
72 ž 21 ATLAS OF ESRD IN THE UNITED STATES Figure 3.4 Modality by age, race/ethnicity, primary diagnosis, & gender patients, 1999 In both genders, more than 68% of pediatric patients have a functioning transplant. This number averages only 8.4% for patients 65 and older, over 86% of whom are on hemodialysis. Though the difference is small, whites and Asians of both genders are more likely to be on peritoneal dialysis than blacks and Native Americans, and patients with a primary diagnosis of diabetes or hypertension have the least likelihood of receiving a transplant. 1 8 6 4 2 1 Male Hemodialysis Peritoneal dialysis Transplant -19 2-44 45-64 65+ Female -19 2-44 45-64 65+ Percent of patients on modality 8 6 4 2 White Black N Am Asian Hispanic White Black N Am Asian Hispanic 1 8 6 4 2 DM GN HTN Cys. kid. DM GN HTN Cys. kid. Table 3.1 Percent distribution of patients by modality patients, 1999 Functioning Center Home Other Total transplant hemo hemo CAPD CCPD PD -19 5,724 72.4 16..3 1.9 9..3 2-44 77,782 5.4 41.6.9 4.1 2.9.1 45-64 132,28 33.9 58.1 1. 4.3 2.6.1 65+ 115,534 8.4 84.7.9 3.6 2.4. Male 18,718 32.1 6.7.9 3.6 2.6.1 Female 15,62 26.5 65.3 1. 4.4 2.8.1 White 24,14 36.4 55.5.8 4.3 2.9.1 Black 19,357 16.9 76.5 1.1 3.1 2.3.1 Native American 5,316 22.2 68.8 2.7 4.3 2.. Asian 12,543 31.5 6..9 4.8 2.8.1 Hispanic 32,839 27.2 65.2 1. 3.7 2.9.1 Non-Hispanic 298,481 29.8 62.5.9 4. 2.7.1 Diabetes 112,673 17.5 74.7.7 4.3 2.7.1 Hypertension 76,855 16. 76.5 1.1 3.8 2.6. Glomerulonephritis 52,843 45.8 45.2 1.2 4.5 3.2.1 Cystic kidney 14,615 53. 39. 1. 4.1 2.8. All 331,32 29.5 62.8.9 4. 2.7.1
C H A P T E R 3 TREATMENT MODALITIES 73 Figure 3.5 Percent distribution of patients: hemodialysis December 31st point prevalent patients, 1999, by HSA, smoothed The mean percentage of patients on hemodialysis is 51% greater in the highest quintile (primarily the southeastern portion of the country) than in the lowest. 67.9+ (73.5) 62.4 to <67.9 57.3 to <62.4 52.1 to <57.3 below 52.1 (48.8) Figure 3.6 Percent distribution of patients: peritoneal dialysis December 31st point prevalent patients, 1999, by HSA, smoothed The mean percentage of patients on peritoneal dialysis is three and a half times greater in the highest quintile than in the lowest. 1.2+ (14.3) 8. to <1.2 6.4 to <8. 5.1 to <6.4 below 5.1 (4.1) Figure 3.7 Percent distribution of patients: transplant December 31st point prevalent patients, 1999, by HSA of patient residence, smoothed The mean percentage of patients with functioning transplants is more than twice as large in the highest quintile (primarily the northern and northwestern portions of the country) than in the lowest. 38.7+ (44.) 33.4 to <38.7 29.3 to <33.4 23.9 to <29.3 below 23.9 (19.9)
74 ž 21 ATLAS OF ESRD IN THE UNITED STATES Figure 3.8 Median age & modality, by ESRD network patients, 1997 1999 combined The percentages of treatment modalities add up to 1%. The median age of the prevalent population is lowest in Network 16 at 55 years, and highest in Network 7 at 6 years. Network 16 has the lowest percent of patients on hemodialysis (52.3%), and Network 6 the highest (7.7%), while patients in Network 12 (1.8%) have the greatest likelihood of being placed on peritoneal dialysis. The highest proportion of transplant patients occurs in Networks 11 and 16. 16 8 11 15 6 9 1 12 13 14 17/18 2 5 1 3 4 7 Network 4 14 7 1 8 2 13 17/18 5 15 11 6 16 1 9 3 12 Median age in years 55 56 57 58 59 6 Percent on peritoneal dialysis 5 6 7 8 9 1 11 16 11 12 1 9 1 15 17/18 4 7 2 3 5 8 14 13 6 6 3 13 5 8 2 14 7 17/18 4 9 15 12 1 1 11 16 Percent on hemodialysis 54 56 58 6 62 64 66 68 7 Percent with functioning transplant 22 26 3 34 38 Table 3.2 Percent distribution of patients, by modality & ESRD network ESRD patients, 1997 1999 combined Dialysis percentages add across to 1%. The functioning transplant column shows the percentage of patients aged 64 who have functioning transplants. Median Funct. tx Center Home Other PD/ Network age age -64 hemo hemo CAPD CCPD unknown 1 (CT, MA, ME, NH, RI, VT) 59 49.8 82.8 1.4 7.1 5.8 2.9 2 (NY) 58 34.9 86.7 1.5 6.2 3.1 2.4 3 (NJ, Puerto Rico, Virgin Isl.) 59 3.8 83.4 1.3 6.6 6.2 2.5 4 (DE, PA) 59 43.7 88.2 1.2 4.3 3.4 2.8 5 (DC, MD, VA, WV) 58 32.6 86.5 1.7 5.5 4. 2.2 6 (GA, NC, SC) 57 27.7 85.2 2.1 6. 4.3 2.4 7 (FL) 6 36.1 86. 3.5 4.1 4.2 2.2 8 (AL, MS, TN) 56 33. 87.5 1.6 5.4 3.7 1.8 9 (IN, KY, OH) 57 43.1 82.4 1.3 9.2 4.3 2.7 1 (IL) 57 45.9 85.4 1.4 6. 3.8 3.4 11 (MI, MN, ND, SD, WI) 56 52.8 84. 1.5 9. 3.5 2. 12 (IA, KS, MO, NE) 57 45.7 79.2 1.8 11.1 4.6 3.4 13 (AR, LA, OK) 57 32.1 87.2 1.9 5.9 3.3 1.6 14 (TX) 57 33.2 89. 1.2 3.9 4. 2. 15 (AZ, CO, NM, NV, UT, WY) 56 43. 85.4 1.3 6.4 4.4 2.6 16 (AK, ID, MT, OR, WA) 55 5.6 81. 2.6 9.9 4. 2.6 17/18 (CA, HI) 57 4.5 86.5.8 6.7 3.6 2.5 Unknown Network 48 83.6 53.1 1.4 3.9 2.7 39. All 57 39.4 85.4 1.6 6.5 4. 2.5
CHAPTER 3 ž TREATMENT MODALITIES ž 75 Percent of patients 1 8 6 4 Hemodialysis Peritoneal dialysis Transplant 1991 1994 1996 Figure 3.9 Modality at initiation, one year, & two years all incident Medicare patients who survive 9 days While the percent of patients on hemodialysis is consistently less at two years than at initiation, the percent of patients on this modality at initiation, at one year, and at two years has increased steadily since 1991. 2 Initiation 1 year 2 years Initiation 1 year 2 years Initiation 1 year 2 years Percent of patients 1 9 8 7 6 5 4 3 Hemodialysis Peritoneal dialysis Transplant Death Figure 3.1 Modality & death at two years after first ESRD service, by age incident patients, 1995 1997 combined At two years following the first therapy for ESRD, 54.7% of pediatric patients have a functioning transplant, and only 6.3% have died. In patients 65 and older, in contrast, 52.7% have died, and 42.5% are on hemodialysis. 2 1-19 2-44 45-64 65+ Relative risk 1.4 1.2 1..8 Figure 3.11 Relative risk (Cox model) of changing dialytic modalities incident Medicare adult dialysis patients, 1991 1998, with oneyear follow-up, adjusted for age, gender, race, diabetic status, & incident year Reference group: age 45 54, male, white, non-diabetic, 1995. The likelihood of changing dialytic modalities was 22% higher in 1996 than in 1995. In 1998, patients were significantly less likely to change modalities, which may reflect greater selection bias towards patients chosen to go on peritoneal dialysis..6 1991 1992 1993 1994 1995 1996 1997 1998
76 ž 21 ATLAS OF ESRD IN THE UNITED STATES Hemodialysis, white (ref: Illinois) Hemodialysis, black (ref: California) 1.9+ (1.14) 1.3 to <1.9.99 to <1.3.92 to <.99 below.92 (.82) 1.7+ (1.1) 1.4 to <1.7.98 to <1.4.91 to <.98 below.91 (.82) Peritoneal dialysis, white (ref: Kentucky) Peritoneal dialysis, black (ref: West Virginia) 1.27+ (1.61) 1.1 to <1.27.95 to <1.1.79 to <.95 below.79 (.66) 1.4+ (2.24) 1.1 to <1.4.95 to <1.1.67 to <.95 below.67 (.23) Transplant, white (ref: Kentucky) Transplant, black (ref: Maryland) 1.11+ (1.27) 1.3 to <1.11.97 to <1.3.89 to <.97 below.89 (.83) 1.34+ (1.8) 1.3 to <1.34.91 to <1.3.79 to <.91 below.79 (.69) Figure 3.12 Relative risk of being on a modality, by race/ethnicity patients, 1999, by state The national median state is used as the baseline for each map. The mean relative risk of being on hemodialysis varies 39% and 34% between the lowest and highest quintiles for whites and blacks, respectively. For peritoneal dialysis, however, this difference is 144% for whites, and almost 9% for blacks. The mean relative risk of being a transplant patient differs 53% for whites between the outer quintiles, 161% for blacks, and 381% for Hispanics. Black patients in the southeastern states have the highest risk of being on hemodialysis, while those living in the northeast and in Minnesota, Montana, Wyoming, Utah, Alaska, and Hawaii are most likely to be transplanted. The highest relative risk of transplantation for Hispanic patients occurs in Louisiana and in the midwest and northwest portions of the country.
CHAPTER 3 ž TREATMENT MODALITIES ž 77 Hemodialysis, Hispanic (ref: Michigan) Hemodialysis, other (ref: Georgia) 1.15+ (1.29) 1.4 to <1.15.92 to <1.4.75 to <.92 below.75 (.55) insuff. data 1.12+ (1.28) 1.3 to <1.12.91 to <1.3.86 to <.91 below.86 (.68) Peritoneal dialysis, Hispanic (ref: Pennsylvania) Peritoneal dialysis, other (ref: Massachusetts) Transplant, Hispanic (ref: Minnesota) 1.54+ (3.18) 1. to <1.54.51 to <1..24 to <.51 below.24 (.) insuff. data Transplant, other (ref: Kansas) 1.28+ (1.63) 1.15 to <1.28.96 to <1.15.7 to <.96 below.7 (.38) 1.7+ (2.7) 1.11 to <1.7.85 to <1.11.72 to <.85 below.72 (.43) insuff. data Figure 3.12 (continued) Relative risk of being on a modality, by race/ethnicity patients,1999, by state The national median state is used as the baseline for each map. 1.29+ (1.61) 1.13 to <1.29.97 to <1.13.84 to <.97 below.84 (.55)
78 ž 21 ATLAS OF ESRD IN THE UNITED STATES Figure 3.13 Percent of living ESRD patients, by ESRD duration & modality patients, 1999 Almost 7% of patients who have lived ten or more years with ESRD have a functioning transplant, while approximately 3% are on hemodialysis and only 3% are on peritoneal dialysis. Percent of patients on modality 1 9 8 7 6 5 4 3 2 1 Hemodialysis Peritoneal dialysis Transplant 1 2 3 4 5 6 7 8 9 1 11 12 13 14 Total years of ESRD