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Disclosures: Weinhandl reports a consulting relationship with Fresenius Medical Care North America, providing input in epidemiologic research about home dialysis. Please see the study for all other authors’ relevant financial disclosures.
July 26, 2021
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Number of patients treated for ESKD drops for first time; census ‘may be nearing an apex’

Disclosures: Weinhandl reports a consulting relationship with Fresenius Medical Care North America, providing input in epidemiologic research about home dialysis. Please see the study for all other authors’ relevant financial disclosures.
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The number of patients receiving treatment for end-stage kidney disease in April was 0.6% lower than a year ago, the first such year-to-year drop in patient census since 1980, a new study shows.

Eric D. Weinhandl

“Between week 1 of 2015 and week 13 of 2020, the numbers of dialysis and transplant patients steadily increased, with little deviation from quadratic trends,” Eric D. Weinhandl, PhD, MS, and colleagues from the Chronic Disease Research Group at the Hennepin Healthcare Research Institute in Minneapolis, wrote.

USRD system data

At the time, there were 808,354 patients with ESKD, with 572,157 patients undergoing dialysis and 236,197 patients with a transplant, based on United States Renal Data System data.

One year later, however, that number dropped to 803,661 patients, “representing a year-over-year decline of 0.6% and a ‘deficit’ of 3.8%, relative to the forecast of 833,236 ESKD patients,” the authors wrote. “In all dialysis patient subgroups except Asian patients, the census declined.”

The largest deficits were seen among patients 75 years old and older.

COVID-19 pandemic

While the authors acknowledged that high mortality among prevalent patients from COVID-19 in the past year contributed to the lower number of patients receiving treatment for ESKD, the drop “has direct consequences for outpatient dialysis capacity and corresponding labor needs in the next several years,” they wrote, “especially considering the drive toward greater adoption of home dialysis modalities.”

Likewise, “as the base payment for an outpatient hemodialysis session covered by Part B has increased from $229.63 in 2011 to $239.33 in 2020, dialysis providers have relied on steadily increasing treatment volume to address treatment cost inflation.

“For small and rural dialysis providers, which are more likely to operate with negative margins, any decrease in the number of dialysis patients is a potential existential threat to operations, possibly forcing further consolidation among providers.”

They added, “During the early part of the pandemic, all-cause mortality was 17% and 30% higher than expected among dialysis and transplant patients, respectively, while the number of patients who initiated kidney replacement therapy (KRT) declined sharply.

“Considering that the rate of COVID-19 hospitalization was approximately 40 times higher among dialysis patients than in the general population, it is likely that substantial mortality also occurred during the past winter.”

As the COVID-19 pandemic slows, “it is plausible that the ESKD population in the United States will grow again,” the authors concluded. “After all, the U.S. population is aging, thereby placing upward pressure on ESKD incidence.

“Nevertheless, with essentially static adjusted incidence of ESKD and likely expansion of sodium-glucose cotransporter-2 inhibitor utilization, it is also possible that the number of dialysis patients in the country is nearing an apex, thus providing an opportunity for the ESKD population to shift away from its long-standing mixture of 70% of patients undergoing dialysis and 30% of patients with a functioning transplant ... Continued surveillance will be necessary to guide the nephrology community and policymakers alike,” the authors wrote.