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Epidemiology and Outcomes |
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* Departments of Epidemiology and Biostatistics, Johns Hopkins Bloomberg School of Public Health; Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Medical Institutions; and Department of Medicine, Johns Hopkins University, School of Medicine, Baltimore; || Social & Scientific Systems, Inc., Silver Spring; ¶ Division of Kidney, Urologic, and Hematologic Diseases, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda; and # Division of Health and Nutrition Examination Surveys, National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland
Address correspondence to: Dr. Josef Coresh, 2024 E. Monument Street, Baltimore, MD 21205. Phone: 410-955-0495; Fax: 410-955-0476; E-mail: coresh{at}jhu.edu
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Abstract |
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30 mg/g) in single spot urine increased from 8.2 ± 0.4% to 10.1 ± 0.7% (P = 0.01). Overall CKD prevalence was similar in both surveys (9% using ACR > 30 mg/g for persistent microalbuminuria; 11% in 1988 to 1994 and 12% in 1999 to 2000 using gender-specific ACR cutoffs). Despite a high prevalence, CKD awareness in the U.S. population is low. In contrast to the dramatic increase in treated kidney failure, overall CKD prevalence in the U.S. population has been relatively stable. |
Introduction |
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Estimates based on the Third National Health and Nutrition Examination Survey (NHANES III; conducted from 1988 to 1994) suggest that 11% of U.S. adults had CKD and 4% of adults had decreased kidney function (3–5). In Medicare billing data (2), CKD was diagnosed in 1.2 million older adults in 2002, substantially fewer than the 7 million adults over the age of 65 with decreased kidney function and CKD based on NHANES III (4). CKD is associated with a two- to threefold higher risk of death, in addition to a higher risk of requiring dialysis and developing congestive heart failure or other cardiovascular event (6). Despite this higher risk, preventative care including lipid monitoring and glycemic monitoring among individuals with diabetes was no higher among Medicare patients with CKD than in patients without CKD (2,6). Chart review of patient populations also suggests that CKD is often undiagnosed, and complications of later stages of CKD are often untreated (7–9). It is also unknown how often adults with CKD are aware that they have kidney disease even though patient and physician education is a major goal of the National Kidney Disease Education Program (www.nkdep.nih.gov).
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Materials and Methods |
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Measurements
BP was measured during the home interview and in the MEC in NHANES III and in the MEC only in NHANES 1999 to 2000. The arithmetic averages of all available diastolic and systolic measurements were used. A random spot urine sample was obtained from MEC-examined participants, using a clean-catch technique and sterile containers, and frozen nonhematuric specimens were analyzed (10,14). Urine albumin and creatinine concentrations were measured in the same laboratory during both surveys: albumin was measured by solid-phase fluorescence immunoassay, and urine creatinine was measured by the modified kinetic method of Jaffe using a Beckman Coulter Synchron AS/Astra Analyzer. Serum creatinine was measured by the modified kinetic method of Jaffe using a Roche Hitachi 737 analyzer in the 1988 to 1994 survey and using a Hitachi 917 analyzer in the 1999 to 2000 survey (10,15).
Definitions
The CKD stages are those provided by the Kidney Disease Outcomes Quality Initiative (3). Participant demographics are based on self-reported age and race/ethnicity elicited during the NHANES interviews. Those who responded "yes" to the question, "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys (excluding kidney stones, bladder infections, or incontinence)?" were defined as aware of kidney disease. Participants who responded "yes" to the question, "Have you ever been told by a doctor or other health professional that you had diabetes or sugar diabetes?" were defined as having diabetes. Hypertension was defined as present when either one of two criteria applied: (1) the participant self-reported a previous doctor diagnosis of hypertension and was currently taking prescription medication for the condition, or (2) the participant had average systolic pressure 140 mmHg or average diastolic pressure 90 mmHg.
Urinary albumin-to-creatinine ratio (ACR) was computed and is reported in milligrams per gram. Microalbuminuria is defined as an ACR of 30 to < 300 mg/g. Participants with ACR 300 mg/g were defined as having macroalbuminuria. These definitions are consistent with consensus endorsements for determining abnormal levels of albumin excretion in random spot urine collections (16,17). Gender-specific ranges for microalbuminuria and macroalbuminuria that account for higher creatinine excretion in men than women were also used in calculating the prevalence of CKD stages 1 and 2 (3,4,18).
Kidney function was assessed by estimating GFR with the simplified Modification of Diet in Renal Disease Study (MDRD) prediction equation (3). Specifically, estimated GFR = 186.3 x (serum creatinine in mg/dl)–1.154 x age–0.203 x (0.742 if female) x (1.21 if black). Before use in the formula, the value of 0.13 was added to the reported serum creatinine concentration for NHANES 1999 to 2000 participants and the value of 0.23 was subtracted from the reported serum creatinine concentration for NHANES 1988 to 1994 participants. These serum creatinine adjustments align the NHANES measures with the creatinine assays used in the development of the MDRD equation (19). Estimated GFR is reported in ml/min per 1.73 m2. Values that exceeded 200 ml/min per 1.73 m2 were truncated at that level, and individuals with values <60 ml/min per 1.73 m2 are characterized as having decreased kidney function.
Statistical Analyses
This study is limited to MEC-examined participants who were aged 20 yr and older and had measures of estimated GFR 15 ml/min per 1.73 m2 (n = 15,488 in NHANES III and n = 4101 in NHANES 1999 to 2000). Adults with insufficient data to estimate GFR (6% in 1988 to 1994 and 7% in 1999 to 2000) were excluded. Strata for the presentation of statistics include gender (male or female), age group (20 to 39, 40 to 59, 60 to 69, or 70+ years), race/ethnicity (non-Hispanic white, non-Hispanic black, Mexican American, or other), diagnosed diabetes (yes or no), and hypertension status (on medication, not taking medication but with high BP, or no evidence of hypertension).
Estimated kidney function was classified into four categories (GFR 15 to 29, 30 to 59, 60 to 89, and 90+ ml/min per 1.73 m2), and prevalence statistics for each GFR level were computed for the overall population, as well as for each strata variable. Severely and moderately decreased kidney functions are often combined to provide a single, more precise estimate of decreased kidney function (GFR 15 to 59 ml/min per 1.73 m2). Similarly, the prevalence of ACR levels (< 30, 30 to 299, 300 mg/g) in the overall population and for all strata variables were computed, excluding people with missing ACR data and women who were pregnant or in menses. Inferences were based on comparisons of 95% confidence interval (CI) estimates, and P < 0.05 was considered statistically significant.
All prevalence estimates and percentiles of the distribution of GFR by age were computed using sampling weights provided by National Center for Health Statistics, and SE were computed in accordance with recommended procedures for NHANES 1999 to 2000 including the delete 1 jackknife method (11,20). The weights account for differential nonresponse and probability of selection. Thus, the results apply to the civilian noninstitutionalized U.S. population. NHANES 1988 to 1994 estimates best represent the survey midpoint, October 1991. Analyses were performed using SUDAAN software (RTI, Research Triangle Park, NC) for the analysis of complex survey data.
Population estimates of the percentage affected by CKD were computed separately for each of four stages of CKD, defined in accordance with the National Kidney Foundation classification system (3) and summed. The algorithms for calculating percentages (PCT) in each group were: PCT(stage 4) = PCT(GFR 15 to 29); PCT(stage 3) = PCT(GFR 30 to 59): PCT(stage 2) = PCT(ACR 300 | GFR 60 to 89) x PCT(GFR 60 to 89) + (0.75) x PCT(ACR 30 to 299 | GFR 60 to 89) x PCT(GFR 60 to 89); PCT(stage 1) = PCT(ACR 300 | GFR 90+) x PCT(GFR90+) + (0.509) x PCT(ACR 30 to 299 | GFR 90+) x PCT(GFR90+). The multiplying constants, 0.75 and 0.509, represent assumed levels of persistent microalbuminuria (30 to 299 mg/g) and were derived from repeat measures in a subset of NHANES 1988 to 1994 participants using similar methods to previous national estimates (4,10). CI for CKD prevalence estimates and ratios that combine the sampling variation of each number in the calculation, including the albuminuria persistence rates, were calculated using bootstrapping methods implemented in Stata (Stata Corp., College Station, TX).
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Results |
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Both hypertension and a history of diabetes were associated with a high prevalence of decreased kidney function and albuminuria (Figure 3). In the absence of these conditions, decreased kidney function and albuminuria were uncommon in the population as a whole (1.4 and 6%, respectively, in 1999 to 2000). Age is an important factor, and even in the absence of hypertension and self-reported diabetes, 12% of adults aged 65 yr or older had decreased kidney function and 11% had albuminuria (1999 to 2000 data in Figure 3).
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30 mg/g) increased from 8.2 ± 0.4% in 1988 to 1994 to 10.1 ± 0.7% in 1999 to 2000 (P = 0.01). Generally, this pattern of higher rates in 1999 to 2000 compared with 1988 to 1994 was observed across gender, age, and race/ethnicity groups. The prevalence of macroalbuminuria was higher in non-Hispanic blacks compared with non-Hispanic whites. Individuals with a history of diabetes had a much higher prevalence of albuminuria in both surveys but showed a somewhat different pattern in the two surveys (Figure 3). Among individuals with diabetes, the results are suggestive that the prevalence of macroalbuminuria increased from 1988 to 1994 to 1999 to 2000, whereas the prevalence of microalbuminuria showed the opposite pattern, although neither difference was statistically significant
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Discussion |
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Although comparable proportions of men and women with albuminuria responded in the affirmative, women with decreased kidney function were less likely to report ever being told that they had weak or failing kidneys. This discrepancy likely reflects misinterpretation by providers of the lower mean and range of serum creatinine for women with stage 3 CKD than that for men (1.2 mg/dl, range 0.9 to 1.9 for women versus 1.6 mg/dl, range 1.1 to 2.5 for men). We suspect that health care providers are especially prone to overlooking CKD in older women, who often have a serum creatinine that is in the normal range for younger individuals. This finding highlights the importance of using GFR estimating equations that incorporate age and gender as variables. Future rounds of NHANES data will increase the sample size and allow for analyses of multiple factors (race, socioeconomic status, and health care utilization) associated with awareness of CKD not possible with only the NHANES 1999 to 2000 survey.
The results of this study show a high but relatively stable prevalence of CKD among U.S. adults. During 1999 to 2000 (Table 3), an estimated 3.8% (95% CI 3.1 to 4.6%) of U.S. adults (approximately 7 million individuals) had CKD on the basis of decreased kidney function (GFR 15 to 59 ml/min per 1.73 m2, corresponding to CKD stages 3 and 4). An additional 5.6% of the U.S. population (11.3 million) had persistent albuminuria with a normal or only mildly decreased kidney function (GFR 60 ml/min per 1.73 m2), corresponding to CKD stages 1 and 2. These numbers far exceed the number of cases of treated ESRD (88,000 new cases and 436,000 treated cases in 1999 [2]), consistent with either nonprogression or a higher rate of mortality than progression to kidney failure in the majority of patients with CKD. Decreased kidney function was an independent risk factor of cardiovascular disease and all-cause mortality in several studies in the general population and among high-risk individuals (23). Medicare enrollees with a CKD diagnosis had a 5 to 10 times higher risk of death than ESRD (6). On the basis of these observations, the discrepancy between the size of the CKD pool and the incidence of ESRD may be derived in part from premature cardiovascular death in many people before progression to ESRD.
It was surprising that overall estimates of CKD based on the 1988 to 1994 and 1999 to 2000 data are very similar. Although this near constancy provides some confidence that the estimates are generally reliable, the stability of the CKD pool is at odds with a >50% increase in ESRD incidence during that interval. These data suggest that the greater increase in the incidence of ESRD may reflect increasing treatment rates, a higher rate of progression of CKD to ESRD, and/or lesser rates of competing mortality, presumably as a result of less premature cardiovascular death. An independent analysis comparing changes in CKD prevalence in NHANES II (1976 to 1980) and NHANES III (1988 to 1994) to ESRD trends has recently noted the same discrepancy in the 1980s that we report for the 1990s with the rising incidence of ESRD far outpacing any increase in the CKD pool (25% increase in CKD stage 3 to 4 versus 2.6-fold increase in the number of incident ESRD cases) (24). Additional data on this issue are needed, particularly because progression of CKD to ESRD can take many years, suggesting that a longer period of observation than a decade would be useful.
Estimates from a large sample of Medicare data suggest that CKD diagnosis among older individuals has doubled over the past decade from 0.6 to 1.2 million Medicare enrollees (2). Thus, trends in the prevalence of severe CKD, such as stage 4, and its diagnosis may differ from the trends shown here, which largely reflect the earlier and more common stages of CKD (stages 1 to 3). The observation of a greater prevalence of albuminuria in the general population and a possibly higher prevalence of macroalbuminuria among the growing number of adults with diabetes is consistent with more rapid progression as at least one contributor to ESRD growth. The growing prevalence of diabetes is estimated to explain 28% of the increase in ESRD from 1978 to 1991 (25). A reduction in competing mortality from stroke and myocardial infarction does explain a small portion (approximately 5%) of the expansion of ESRD between 1978 and 1991 (25). The degree to which these factors have contributed to the continued rise in ESRD since 1991 is uncertain. Other environmental and iatrogenic factors, such as radiologic contrast media, may also alter the balance between early CKD and ESRD (20). Whatever the reasons, the burden of CKD in the population, although persistently high, does not, on its own, explain the rise in the incidence of treated kidney failure.
As expected, the prevalence of CKD was higher in hypertension, diabetes, and older age. Surprising, the prevalence of moderately and severely decreased kidney function is similar among blacks and non-Hispanic whites. This similarity is perplexing given the approximately fourfold increased risk of ESRD in the black compared with the white population (2). This seemingly paradoxical observation is consistent between the 1988 to 1994 and 1999 to 2000 surveys and remains after adjustment for age and gender (Table 1) as well as previous analyses of the 1988 to 1994 data (4,26). Several possibilities may explain the similar prevalences of CKD. Rates of progression to ESRD are faster in blacks, and they therefore would be expected to have more rapid movement through the CKD pool (27). The greater prevalence of macroalbuminuria in blacks (2.4 ± 0.61%) than in whites (1.0 ± 0.24%; P = 0.03) in 1999 to 2000 (Table 2) further supports more rapid progression. Furthermore, risk of myocardial infarction, at least among people with diabetes, is greater in whites (28). Hence, competing mortality from cardiovascular death may remove whites from the incident ESRD population. The MDRD equation does assign a higher GFR for blacks than for whites at any given level of serum creatinine. Although this empiric adjustment has been confirmed in a large sample of blacks beyond the original study population (29), any racial comparison of renal function on the basis of serum creatinine is sensitive to modeling correctly the quantitative difference in creatinine metabolism in blacks and whites. Finally, poorer care directed at attenuating or interdicting the progression of CKD might occur in blacks. Considerable data attest to such racial disparities, including later referral of black men with CKD to specialty consultation (30). Further research is needed to determine which hypotheses explain the higher risk of ESRD among minority populations.
It is worth noting several limitations and strengths of the current study. First, estimating GFR from serum creatinine has well-recognized limitations, including substantial variation in creatinine production by age, gender, and race (31). To minimize the impact of these limitations, we used a newly developed equation with increased precision of estimating GFR and calibrated the serum creatinine measurements to the laboratory that generated the data for development of this equation (19). Although the number of blacks and individuals with a GFR > 60 was limited in the initial development of this formula, a recent large study has shown that the equation performs very well among hypertensive blacks (29). Still, the ability to estimate GFR accurately in the normal range (>90 ml/min per 1.73 m2) and in the general population is uncertain because it is an extrapolation of the MDRD study data. However, low GFR estimates from general population samples calculated using the MDRD study equation are associated with CKD complications and cardiovascular risk (3,23). The study of trends in CKD prevalence estimates from two NHANES surveys is less susceptible to bias because potential biases from each survey estimate outlined previously (3) are likely to operate similarly in two surveys.
Several methodologic limitations apply to this use of NHANES data. Although the data are designed specifically to assess disease burden cross-sectionally in a national representative sample, they are limited in their ability to address disease risk and cause. Comparisons across surveys are subject to potential bias if unmeasured changes occur in data collection over time. The number of individuals with moderately decreased kidney function is not very large (n = 881 in NHANES III and 231 in NHANES 1999 to 2000) and the number with severely decreased kidney function (n = 45 in NHANES III and 10 in NHANES 1999 to 2000) is small, limiting the power of subgroup comparisons. For this reason, analyses focus on moderately reduced kidney function (GFR 30 to 59 ml/min per 1.73 m2) or reduced kidney function overall (GFR 15 to 59 ml/min per 1.73 m2) among individuals without kidney failure (GFR > 15 ml/min per 1.73 m2). Nationally representative studies are most powerful for comparing stages 1 to 3 CKD, for which the prevalence of each stage is > 3% and the prevalence among older individuals is > 10%. CKD estimates are adjusted to focus on persistent albuminuria, but repeat albuminuria data were available only on a subset of the participants in NHANES III, limiting the precision of the stages 1 and 2 CKD prevalence estimates. Changes in persistence of albuminuria would affect the prevalence estimates of CKD, although the confidence interval presented include the uncertainty in the persistence estimate.
This analysis of CKD within the most recent NHANES 1999 to 2000 indicates three remarkable features. First, the awareness of CKD is low and a disparity exists such that women are far less apt to be aware of having decreased kidney function (GFR < 60 ml/min per 1.73 m2) than men. Second, although the burden of CKD is high, it has not increased substantially in nearly a decade since NHANES III, even though the incidence of ESRD has risen by >50% during that interval. Finally, whites and blacks share approximately the same prevalence of CKD overall despite the fourfold greater incidence of ESRD in blacks group. Given the high prevalence of CKD, efforts to increase awareness, diagnosis, and treatment are needed to meet the Healthy People 2010 goal of reducing new cases of CKD and its complications, disability, death, and economic costs (2).
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Acknowledgments |
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Footnotes |
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R. J. Glassock and C. Winearls An epidemic of chronic kidney disease: fact or fiction? Nephrol. Dial. Transplant., April 1, 2008; 23(4): 1117 - 1121. [Full Text] [PDF]
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J. Coresh, L. A. Stevens, and A. S. Levey Chronic kidney disease is common: What do we do next? Nephrol. Dial. Transplant., April 1, 2008; 23(4): 1122 - 1125. [Full Text] [PDF]
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B. G. Jaar, R. Khatib, L. Plantinga, L. E. Boulware, and N. R. Powe Principles of Screening for Chronic Kidney Disease Clin. J. Am. Soc. Nephrol., March 1, 2008; 3(2): 601 - 609. [Full Text] [PDF]
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S. V. Shah, J. Feehally, and on behalf of the World Kidney Day Steering Committ The Third World Kidney Day: Looking Back and Thinking Forward Clin. J. Am. Soc. Nephrol., March 1, 2008; 3(2): 309 - 311. [Full Text] [PDF]
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C. L. Davis, W. E. Harmon, J. Himmelfarb, T. Hostetter, N. Powe, P. Smedberg, L. A. Szczech, P. S. Aronson, and for the American Society of Nephrology Public Poli World Kidney Day 2008: Think Globally, Speak Locally J. Am. Soc. Nephrol., March 1, 2008; 19(3): 413 - 416. [Full Text] [PDF]
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H. Bang, M. Mazumdar, L. M. Kern, D. A. Shoham, P. A. August, and A. V. Kshirsagar Validation and Comparison of a Novel Screening Guideline for Kidney Disease: KEEPing SCORED Arch Intern Med, February 25, 2008; 168(4): 432 - 435. [Full Text] [PDF]
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N. Bassilios, P. Martel, V. Godard, M. Froissart, J.-P. Grunfeld, B. Stengel, and on behalf of the Reseau Nephropar Monitoring of glomerular filtration rate in lithium-treated outpatients--an ambulatory laboratory database surveillance Nephrol. Dial. Transplant., February 1, 2008; 23(2): 562 - 565. [Abstract] [Full Text] [PDF]
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S. V. Shah and J. Feehally The third World Kidney Day: looking back and thinking forward Nephrol. Dial. Transplant., February 1, 2008; 23(2): 471 - 473. [Full Text] [PDF]
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Writing Group Members, W. Rosamond, K. Flegal, K. Furie, A. Go, K. Greenlund, N. Haase, S. M. Hailpern, M. Ho, V. Howard, et al. Heart Disease and Stroke Statistics--2008 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, January 29, 2008; 117(4): e25 - e146. [Full Text] [PDF]
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S. M. Brunelli, J. D. Lewis, M. Gupta, S. M. Latif, M. G. Weiner, and H. I. Feldman Risk of Kidney Injury Following Oral Phosphosoda Bowel Preparations J. Am. Soc. Nephrol., December 1, 2007; 18(12): 3199 - 3205. [Full Text] [PDF]
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T. S. Johnson, M. Fisher, J. L. Haylor, Z. Hau, N. J. Skill, R. Jones, R. Saint, I. Coutts, M. E. Vickers, A. M. El Nahas, et al. Transglutaminase Inhibition Reduces Fibrosis and Preserves Function in Experimental Chronic Kidney Disease J. Am. Soc. Nephrol., December 1, 2007; 18(12): 3078 - 3088. [Full Text] [PDF]
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 J. Coresh, E. Selvin, L. A. Stevens, J. Manzi, J. W. Kusek, P. Eggers, F. Van Lente, and A. S. Levey Prevalence of Chronic Kidney Disease in the United States JAMA, November 7, 2007; 298(17): 2038 - 2047. [Abstract] [Full Text] [PDF]
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M. Ferris, S. L. Hogan, H. Chin, D. A. Shoham, D. S. Gipson, K. Gibson, S. Yilmaz, R. J. Falk, and J. C. Jennette Obesity, Albuminuria, and Urinalysis Findings in US Young Adults from the Add Health Wave III Study Clin. J. Am. Soc. Nephrol., November 1, 2007; 2(6): 1207 - 1214. [Abstract] [Full Text] [PDF]
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J. K. Inrig, B. S. Gillespie, U. D. Patel, L. P. Briley, L. She, J. D. Easton, E. Topol, and L. A. Szczech Risk for Cardiovascular Outcomes among Subjects with Atherosclerotic Cardiovascular Disease and Greater-than-Normal Estimated Glomerular Filtration Rate Clin. J. Am. Soc. Nephrol., November 1, 2007; 2(6): 1215 - 1222. [Abstract] [Full Text] [PDF]
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D. P. McDonough New Jersey's Experience: Mandatory Estimated Glomerular Filtration Rate Reporting Clin. J. Am. Soc. Nephrol., November 1, 2007; 2(6): 1355 - 1359. [Abstract] [Full Text] [PDF]
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S. Gao, B. J. Manns, B. F. Culleton, M. Tonelli, H. Quan, L. Crowshoe, W. A. Ghali, L. W. Svenson, B. R. Hemmelgarn, and for the Alberta Kidney Disease Network Prevalence of Chronic Kidney Disease and Survival among Aboriginal People J. Am. Soc. Nephrol., November 1, 2007; 18(11): 2953 - 2959. [Abstract] [Full Text] [PDF]
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R. Agarwal Effects of Statins on Renal Function Mayo Clin. Proc., November 1, 2007; 82(11): 1381 - 1390. [Abstract] [Full Text] [PDF]
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 T. W. Meyer and T. H. Hostetter Uremia N. Engl. J. Med., September 27, 2007; 357(13): 1316 - 1325. [Full Text] [PDF]
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M. S. MacGregor How common is early chronic kidney disease?: A Background Paper prepared for the UK Consensus Conference on Early Chronic Kidney Disease Nephrol. Dial. Transplant., September 1, 2007; 22(suppl_9): ix8 - ix18. [Full Text] [PDF]
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R. N. Foley, C. Wang, A. Ishani, and A. J. Collins NHANES III: Influence of Race on GFR Thresholds and Detection of Metabolic Abnormalities J. Am. Soc. Nephrol., September 1, 2007; 18(9): 2575 - 2582. [Abstract] [Full Text] [PDF]
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 E. N. Taylor, J. P. Forman, and W. R. Farwell Serum Anion Gap and Blood Pressure in the National Health and Nutrition Examination Survey Hypertension, August 1, 2007; 50(2): 320 - 324. [Abstract] [Full Text] [PDF]
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 K. L. Cavanaugh Diabetes Management Issues for Patients With Chronic Kidney Disease Clin. Diabetes, July 1, 2007; 25(3): 90 - 97. [Abstract] [Full Text] [PDF]
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S. M. Hailpern, M. L. Melamed, H. W. Cohen, and T. H. Hostetter Moderate Chronic Kidney Disease and Cognitive Function in Adults 20 to 59 Years of Age: Third National Health and Nutrition Examination Survey (NHANES III) J. Am. Soc. Nephrol., July 1, 2007; 18(7): 2205 - 2213. [Abstract] [Full Text] [PDF]
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J. Himmelfarb, A. Berns, L. Szczech, and D. Wesson Cost, Quality, and Value: The Changing Political Economy of Dialysis Care J. Am. Soc. Nephrol., July 1, 2007; 18(7): 2021 - 2027. [Full Text] [PDF]
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D. M. Kent, T. H. Jafar, R. A. Hayward, H. Tighiouart, M. Landa, P. de Jong, D. de Zeeuw, G. Remuzzi, A.-L. Kamper, A. S. Levey, et al. Progression Risk, Urinary Protein Excretion, and Treatment Effects of Angiotensin-Converting Enzyme Inhibitors in Nondiabetic Kidney Disease J. Am. Soc. Nephrol., June 1, 2007; 18(6): 1959 - 1965. [Abstract] [Full Text] [PDF]
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M. R. Weir Microalbuminuria and Cardiovascular Disease Clin. J. Am. Soc. Nephrol., May 1, 2007; 2(3): 581 - 590. [Abstract] [Full Text] [PDF]
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T. D. DuBose Jr. American Society of Nephrology Presidential Address 2006: Chronic Kidney Disease as a Public Health Threat--New Strategy for a Growing Problem J. Am. Soc. Nephrol., April 1, 2007; 18(4): 1038 - 1045. [Full Text] [PDF]
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A. Kottgen, S. D. Russell, L. R. Loehr, C. M. Crainiceanu, W. D. Rosamond, P. P. Chang, L. E. Chambless, and J. Coresh Reduced Kidney Function as a Risk Factor for Incident Heart Failure: The Atherosclerosis Risk in Communities (ARIC) Study J. Am. Soc. Nephrol., April 1, 2007; 18(4): 1307 - 1315. [Abstract] [Full Text] [PDF]
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M. B. Patwardhan, G. P. Samsa, D. B. Matchar, and W. E. Haley Advanced Chronic Kidney Disease Practice Patterns among Nephrologists and Non-Nephrologists: A Database Analysis Clin. J. Am. Soc. Nephrol., March 1, 2007; 2(2): 277 - 283. [Abstract] [Full Text] [PDF]
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A. S. Levey, S. P. Andreoli, T. DuBose, R. Provenzano, and A. J. Collins Chronic Kidney Disease: Common, Harmful, and Treatable--World Kidney Day 2007 Clin. J. Am. Soc. Nephrol., March 1, 2007; 2(2): 401 - 405. [Full Text] [PDF]
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J. T. Cohen Estimating Glomerular Filtration Rate From Serum Creatinine in the General Population Mayo Clin. Proc., March 1, 2007; 82(3): 385 - 386. [Full Text] [PDF]
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H. Bang, S. Vupputuri, D. A. Shoham, P. J. Klemmer, R. J. Falk, M. Mazumdar, D. Gipson, R. E. Colindres, and A. V. Kshirsagar SCreening for Occult REnal Disease (SCORED): A Simple Prediction Model for Chronic Kidney Disease Arch Intern Med, February 26, 2007; 167(4): 374 - 381. [Abstract] [Full Text] [PDF]
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W. Rosamond, K. Flegal, G. Friday, K. Furie, A. Go, K. Greenlund, N. Haase, M. Ho, V. Howard, B. Kissela, et al. Heart Disease and Stroke Statistics--2007 Update: A Report From the American Heart Association Statistics Committee and Stroke Statistics Subcommittee Circulation, February 6, 2007; 115(5): e69 - e171. [Full Text] [PDF]
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A. S. Levey, S. P. Andreoli, T. DuBose, R. Provenzano, and A. J. Collins Chronic Kidney Disease: Common, Harmful, and Treatable--World Kidney Day 2007 J. Am. Soc. Nephrol., February 1, 2007; 18(2): 374 - 378. [Full Text] [PDF]
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 C. L Buckner, L. Wilson, and C. N. Papadea An Unusual Cause of Elevated Serum Total {beta}hCG Ann. Clin. Lab. Sci., January 1, 2007; 37(2): 186 - 191. [Abstract] [Full Text] [PDF]
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V. G. Athyros, D. P. Mikhailidis, E. N. Liberopoulos, A. I. Kakafika, A. Karagiannis, A. A. Papageorgiou, K. Tziomalos, E. S. Ganotakis, and M. Elisaf Effect of statin treatment on renal function and serum uric acid levels and their relation to vascular events in patients with coronary heart disease and metabolic syndrome: A subgroup analysis of the GREek Atorvastatin and Coronary heart disease Evaluation (GREACE) Study Nephrol. Dial. Transplant., January 1, 2007; 22(1): 118 - 127. [Abstract] [Full Text] [PDF]
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C.-y. Hsu, A. S. Go, C. E. McCulloch, J. Darbinian, and C. Iribarren Exploring Secular Trends in the Likelihood of Receiving Treatment for End-Stage Renal Disease Clin. J. Am. Soc. Nephrol., January 1, 2007; 2(1): 81 - 88. [Abstract] [Full Text] [PDF]
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 A. S. Levey, L. A. Stevens, and T. Hostetter Automatic Reporting of Estimated Glomerular Filtration Rate--Just What the Doctor Ordered Clin. Chem., December 1, 2006; 52(12): 2188 - 2193. [Full Text] [PDF]
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 S. I Hallan, K. Dahl, C. M Oien, D. C Grootendorst, A. Aasberg, J. Holmen, and F. W Dekker Screening strategies for chronic kidney disease in the general population: follow-up of cross sectional health survey BMJ, November 18, 2006; 333(7577): 1047 - 1047. [Abstract] [Full Text] [PDF]
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B. Kiberd The Chronic Kidney Disease Epidemic: Stepping Back and Looking Forward J. Am. Soc. Nephrol., November 1, 2006; 17(11): 2967 - 2973. [Abstract] [Full Text] [PDF]
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G. L. Schwartz and S. C. Textor Early Referral for Chronic Kidney Disease: Good for Those Who Need It, but Who Are They? Mayo Clin. Proc., November 1, 2006; 81(11): 1420 - 1422. [Full Text] [PDF]
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A. D. Rule, R. J. Rodeheffer, T. S. Larson, J. C. Burnett Jr, F. G. Cosio, S. T. Turner, and S. J. Jacobsen Limitations of Estimating Glomerular Filtration Rate From Serum Creatinine in the General Population Mayo Clin. Proc., November 1, 2006; 81(11): 1427 - 1434. [Abstract] [Full Text] [PDF]
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C. A. Peralta, M. G. Shlipak, D. Fan, J. Ordonez, J. P. Lash, G. M. Chertow, and A. S. Go Risks for End-Stage Renal Disease, Cardiovascular Events, and Death in Hispanic versus Non-Hispanic White Adults with Chronic Kidney Disease J. Am. Soc. Nephrol., October 1, 2006; 17(10): 2892 - 2899. [Abstract] [Full Text] [PDF]
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N. R. Powe Reverse Race and Ethnic Disparities in Survival Increase with Severity of Chronic Kidney Disease: What Does This Mean? Clin. J. Am. Soc. Nephrol., September 1, 2006; 1(5): 905 - 906. [Full Text] [PDF]
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 J. Coresh and B. Astor Decreased Kidney Function in the Elderly: Clinical and Preclinical, Neither Benign Ann Intern Med, August 15, 2006; 145(4): 299 - 301. [Full Text] [PDF]
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C. Jacobs Costs and benefits of improving renal failure treatment--where do we go? Nephrol. Dial. Transplant., August 1, 2006; 21(8): 2049 - 2052. [Full Text] [PDF]
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S. I. Hallan, J. Coresh, B. C. Astor, A. Asberg, N. R. Powe, S. Romundstad, H. A. Hallan, S. Lydersen, and J. Holmen International Comparison of the Relationship of Chronic Kidney Disease Prevalence and ESRD Risk J. Am. Soc. Nephrol., August 1, 2006; 17(8): 2275 - 2284. [Abstract] [Full Text] [PDF]
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P. E. de Jong and G. C. Curhan Screening, Monitoring, and Treatment of Albuminuria: Public Health Perspectives J. Am. Soc. Nephrol., August 1, 2006; 17(8): 2120 - 2126. [Abstract] [Full Text] [PDF]
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B. Stengel and C. Couchoud Chronic Kidney Disease Prevalence and Treated End-Stage Renal Disease Incidence: A Complex Relationship J. Am. Soc. Nephrol., August 1, 2006; 17(8): 2094 - 2096. [Full Text] [PDF]
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S. T. Turner, S. L.R. Kardia, T. H. Mosley, A. D. Rule, E. Boerwinkle, and M. de Andrade Influence of Genomic Loci on Measures of Chronic Kidney Disease in Hypertensive Sibships J. Am. Soc. Nephrol., July 1, 2006; 17(7): 2048 - 2055. [Abstract] [Full Text] [PDF]
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L. A. Stevens, J. Coresh, T. Greene, and A. S. Levey Assessing kidney function--measured and estimated glomerular filtration rate. N. Engl. J. Med., June 8, 2006; 354(23): 2473 - 2483. [Full Text] [PDF]
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F. Locatelli, P. Pozzoni, and L. Del Vecchio Renal Manifestations in the Metabolic Syndrome. J. Am. Soc. Nephrol., April 1, 2006; 17(4_suppl_2): S81 - S85. [Abstract] [Full Text] [PDF]
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A. M. O'Hare, D. Bertenthal, K. E. Covinsky, C. S. Landefeld, S. Sen, K. Mehta, M. A. Steinman, A. Borzecki, and L. C. Walter Mortality Risk Stratification in Chronic Kidney Disease: One Size for All Ages? J. Am. Soc. Nephrol., March 1, 2006; 17(3): 846 - 853. [Abstract] [Full Text] [PDF]
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M. Rahman, S. Pressel, B. R. Davis, C. Nwachuku, J. T. Wright Jr., P. K. Whelton, J. Barzilay, V. Batuman, J. H. Eckfeldt, M. A. Farber, et al. Cardiovascular Outcomes in High-Risk Hypertensive Patients Stratified by Baseline Glomerular Filtration Rate Ann Intern Med, February 7, 2006; 144(3): 172 - 180. [Abstract] [Full Text] [PDF]
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R. J. Middleton, R. N. Foley, J. Hegarty, C. M. Cheung, P. McElduff, J. M. Gibson, P. A. Kalra, D. J. O'Donoghue, and J. P. New The unrecognized prevalence of chronic kidney disease in diabetes Nephrol. Dial. Transplant., January 1, 2006; 21(1): 88 - 92. [Abstract] [Full Text] [PDF]
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M. Shlipak and C. Stehman-Breen Observational Research Databases in Renal Disease J. Am. Soc. Nephrol., December 1, 2005; 16(12): 3477 - 3484. [Abstract] [Full Text] [PDF]
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P. Muntner, A. Menke, K. B. DeSalvo, F. A. Rabito, and V. Batuman Continued Decline in Blood Lead Levels Among Adults in the United States: The National Health and Nutrition Examination Surveys Arch Intern Med, October 10, 2005; 165(18): 2155 - 2161. [Abstract] [Full Text] [PDF]
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) and NHANES 1999 to 2000 (
) for adults over the age of 20 and 65 yr. (A) Decreased GFR (< 60 ml/min per 1.73 m2). (B) Albuminuria (micro at ACR 30 to 299 mg/g and macro at