Chapter 1: CKD in the General Population - PowerPoint Presentation

Chapter 1:CKD in the General Population 2017 Annual Data Report Volume 1: Chronic Kidney Disease

2 Table A Kidney Disease Outcomes and Quality Improvement (KDOQI) CKD Staging Guidelines CKD Stage Description GFR (ml/min/1.73 m 2 ) 1 Kidney damage with normal or ↑ GFR > 90 2 Kidney damage with mild ↓ in GFR 60-89 3 Moderate ↓ in GFR 30-59 4 Severe ↓ in GFR 15-29 5 Kidney failure < 15 (or dialysis)

3 vol 1 Figure 1.1 Prevalence of CKD by stage among NHANES participants, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 & older. Whisker lines indicate 95% confidence intervals. Abbreviation: CKD, chronic kidney disease.

4 vol 1 Figure 1.2 eGFR distribution among NHANES participants, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2014 participants aged 20 & older. Single-sample estimates of eGFR ; eGFR calculated using the CKD-EPI equation. Abbreviations: eGFR , estimated glomerular filtration rate; SE, standard error. Accounts for change in serum creatinine assays. (a) All Individuals

5 vol 1 Figure 1.2 eGFR distribution among NHANES participants, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2014 participants aged 20 & older. Single-sample estimates of eGFR ; eGFR calculated using the CKD-EPI equation. Abbreviations: eGFR , estimated glomerular filtration rate; SE, standard error. Accounts for change in serum creatinine assays. (b) Individuals 60+ years

6 vol 1 Figure 1.3 Urine albumin/creatinine ratio (ACR) distribution among NHANES participants, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2014 participants aged 20 & older. Single-sample estimates of ACR. Abbreviation: ACR, urine albumin (mg)/creatinine (g) ratio.

7 vol 1 Figure 1.4 Percentage of NHANES (1999-2014) participants with ACR >30 mg/g, by eGFR category Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2014 participants aged 20 & older. Single-sample estimates of eGFR . Abbreviation: ACR, urine albumin (mg)/creatinine (g) ratio; eGFR , estimated glomerular filtration rate.

8 vol 1 Table 1. 1 Percentage of NHANES 2011-2014 participants, in the various CKD (eGFR and albuminuria) risk categories (KDIGO 2012)   Albuminuria categories A1 A2 A3 Normal to mildly increased Moderately increased Severely increased <30 mg/g <3 mg/mmol 30-300 mg/g 3-30 mg/ mmol >300 mg/g >30 mg/mmol GFR categories (ml/min/1.73 m 2 ) G1 Normal to high ≥90 54.7 4.3 0.4 G2 Mildly decreased 60-89 30.42.60.3G3aMildly to moderately decreased45-593.90.90.2G3bModerately to severely decreased30-441.00.50.2G4Severely decreased15-290.10.10.2G5Kidney failure<15<0.0010.0010.01 Percentage in each category (2011-2014) Data source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 and older. Single-sample estimates of eGFR and ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate; GFR, glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes CKD Work Group. Low risk: eGFR ≥60 ml/min/1.73 m 2 and ACR <30 mg/g; moderately high risk: eGFR 45-59 ml/min/1.73 m 2 or eGFR ≥60 ml/min/1.73 m 2 and ACR 30-300 mg/g; high risk: eGFR 30-44 ml/min/1.73 m 2 or eGFR 45-59 ml/min/1.73 m 2 and ACR 30-300 mg/g or eGFR ≥60 ml/min/1.73 m 2 and ACR >300 mg/g; very high risk: eGFR <30 ml/min/1.73 m 2 or eGFR 30-44 ml/min/1.73 m 2 and ACR 30-300 mg/g or eGFR ≥60 ml/min/1.73 m 2 and ACR >300 mg/g.

9 vol 1 Table 1. 1 Percentage of NHANES 2011-2014 participants, in the various CKD (eGFR and albuminuria) risk categories (KDIGO 2012) Data source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 and older. Single-sample estimates of eGFR and ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate; GFR, glomerular filtration rate; KDIGO, Kidney Disease: Improving Global Outcomes CKD Work Group. Low risk: eGFR ≥60 ml/min/1.73 m 2 and ACR <30 mg/g; moderately high risk: eGFR 45-59 ml/min/1.73 m 2 or eGFR ≥60 ml/min/1.73 m 2 and ACR 30-300 mg/g; high risk: eGFR 30-44 ml/min/1.73 m 2 or eGFR 45-59 ml/min/1.73 m2 and ACR 30-300 mg/g or eGFR ≥60 ml/min/1.73 m2 and ACR >300 mg/g; very high risk: eGFR <30 ml/min/1.73 m2 or eGFR 30-44 ml/min/1.73 m2 and ACR 30-300 mg/g or eGFR ≥60 ml/min/1.73 m2 and ACR >300 mg/g.

10 vol 1 Table 1.2 Prevalence (%) of CKD in NHANES population within age, sex, race/ethnicity, & risk factor categories, 1999-2014   All CKD   eGFR <60 ml/min/1.73m 2   ACR ≥30 mg/g   1999-2002 2003-2006 2007-2010 2011-2014   1999-2002 2003-2006 2007-2010 2011-2014   1999-2002 2003-2006 2007-2010 2011-2014   Age                   20-396.05.95.46.6 0.40.10.30.3      40-5910.09.88.510.6 1.92.32.03.3 5.95.85.36.4 60+36.937.133.632.6 24.025.822.922.6 8.6 8.2 7.0 8.5   Sex                   Male12.012.611.713.0 4.85.75.26.4 9.18.98.48.8 Female15.616.115.016.5 6.87.87.57.9 10.910.29.410.9 Race/Ethnicity               Non-Hispanic White13.914.313.815.2 6.67.97.58.5 9.38.58.49.0 Non-Hispanic Black/African American15.115.814.816.9 5.35.25.86.2 12.713.011.213.5 Mexican American11.611.611.812.5 1.41.62.32.5 10.410.910.511.2 Other Hispanic13.815.511.412.8 3.63.53.34.3 11.713.39.510.5 Other Non-Hispanic14.016.210.612.8 3.94.23.14.3 12.113.59.110.3 Risk Factor               Diabetes41.241.539.039.4 15.119.218.720.7 34.830.928.428.7 Self-reported diabetes40.843.040.640.6 16.520.319.922.3 33.531.729.529.5 Hypertension33.431.730.632.1 16.817.416.917.7 23.019.619.120.6 Self-reported hypertension28.226.925.726.9 16.315.315.015.8 17.716.515.716.6 Self-reported cardiovascular disease38.243.537.242.6 26.729.325.129.3 22.724.822.325.5 Obesity (BMI >30)17.216.816.117.6 6.37.17.07.9 13.211.911.112.5 All13.914.413.414.8 5.86.86.47.2 10.19.68.99.9  Data source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011-2014 participants age 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Diabetes defined as HbA1c >7 percent, self-reported (SR), or currently taking glucose-lowering medications. Hypertension defined as BP ≥130/≥80 for those with diabetes or CKD, otherwise BP ≥140/≥90, or taking medication for hypertension. Values in Figure 1.12 cannot be directly compared to those in Table 1.3 due to different survey cohorts. The table represents NHANES participants who are classified as hypertensive (measured/treated) but some of those are at target blood pressure. Abbreviations: ACR, urine albumin/creatinine ratio; BMI, body mass index; BP, blood pressure, CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate.

11 vol 1 Figure 1.5 Distribution of markers of CKD in NHANES participants with diabetes, hypertension, self-reported cardiovascular disease, & obesity, 2011–2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 2011–2014 participants age 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; BMI, body mass index; CKD, chronic kidney disease; SR CVD, self-reported cardiovascular disease; eGFR , estimated glomerular filtration rate; HTN, hypertension

12 vol 1 Figure 1.6 Adjusted odds ratios of CKD in NHANES participants, by risk factor, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older; single-sample estimates of eGFR & ACR. Adj : age, sex, & race; eGFR calculated using the CKD-EPI equation. Whisker lines indicate 95% confidence intervals. Abbreviations: ACR, urine albumin/creatinine ratio; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; DM, diabetes mellitus; eGFR , estimated glomerular filtration rate; HTN, hypertension; SR, self-report.

13 vol 1 Figure 1.7 Adjusted odds ratios of eGFR <60 ml/min/1.73m2 in NHANES participants, by age & risk factor, 1999-2014 (a) Age category Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older; single-sample estimates of eGFR & ACR. Adj : age, sex, & race; eGFR calculated using the CKD-EPI equation. Whisker lines indicate 95% confidence intervals. Abbreviations: ACR, urine albumin/creatinine ratio; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; DM, diabetes mellitus; eGFR , estimated glomerular filtration rate; HTN, hypertension; SR, self-report.

14 vol 1 Figure 1.7 Adjusted odds ratios of eGFR <60 ml/min/1.73m2 in NHANES participants, by age & risk factor, 1999-2014 (b) CKD Risk Factor Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older; single-sample estimates of eGFR & ACR. Adj : age, sex, & race; eGFR calculated using the CKD-EPI equation. Whisker lines indicate 95% confidence intervals. Abbreviations: ACR, urine albumin/creatinine ratio; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; DM, diabetes mellitus; eGFR , estimated glomerular filtration rate; HTN, hypertension; SR, self-report.

15 vol 1 Figure 1.8 Adjusted odds ratios of urine albumin/creatinine ratio ≥30 mg/g in NHANES participants, by age & risk factor, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older; single-sample estimates of eGFR & ACR. Adjusted: age, sex, & race; eGFR calculated using the CKD-EPI equation. Whisker lines indicate 95% confidence intervals. Abbreviations: ACR, urine albumin/creatinine ratio; BMI, body mass index; CKD, chronic kidney disease; CVD, cardiovascular disease; DM, diabetes mellitus; eGFR , estimated glomerular filtration rate; HTN, hypertension; SR, self-report.

16 vol 1 Table 1.3 Socioeconomic factors among individuals with CKD, percent of NHANES participants, 1999-2014   All CKD   eGFR <60 ml/min/1.73m 2   ACR ≥30 mg/g   1999-2002 2003-2006 2007-2010 2011-2014   1999-2002 2003-2006 2007-2010 2011-2014   1999-2002 2003-2006 2007-2010 2011-2014 Health Insurance Status                  Not Insured11.410.111.413.8 3.93.34.23.9 14.713.214.818.9Insured88.689.988.686.2 96.196.795.896.1 85.386.885.281.1Private Only37.230.030.630.8   22.5 16.8 18.7 22.9   42.2 36.2 35.933.4Medicare Only17.417.415.615.9 23.823.920.923.0 16.214.413.312.3Other Government Only4.95.95.16.9 2.62.33.05.5 5.87.86.28.7Private and any Government21.726.828.622.9 36.641.144.034.2 14.619.321.117.1Other/Unknown7.49.88.79.7 10.612.69.210.5 6.59.18.79.6Income                 Less than $10,00014.57.56.88.0 13.86.14.65.9 16.38.28.39.4$10,000 – $24,99929.728.023.924.5 31.831.826.025.4 29.827.824.225.2$25,000 – $44,99918.823.223.419.8 22.624.724.321.2 17.221.022.619.3$45,000 – $74,99915.320.818.118.9 13.419.819.519.7 14.821.016.717.8$75,000 or more11.414.220.122.6 8.410.916.622.2 11.515.620.821.1Missing10.26.37.76.6 10.06.79.05.5 10.26.47.57.2Education                 < High School33.426.227.122.4 37.027.826.621.3 32.826.329.223.8High School Graduate/GED25.627.126.922.3 26.130.627.522.2 26.325.026.323.5At least some College41.046.746.055.3 36.941.445.956.5 40.948.644.552.7Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate.

17 vol 1 Table 1.4 Health Risk Behaviors among individuals with CKD, percent of NHANES participants, 1999-2014   All CKD   eGFR <60 ml/min/1.73m 2   ACR ≥30 mg/g   1999-2002 2003-2006 2007-2010 2011-2014   1999-2002 2003-2006 2007-2010 2011-2014   1999-2002 2003-2006 2007-2010 2011-2014 Physical Activity                  Vigorous22.420.820.623.3 14.014.813.016.9 24.222.923.524.7Moderate31.535.734.633.1 32.039.035.033.9 30.533.632.931.6Sedentary46.143.544.843.6 53.946.252.049.2  45.3 43.5 43.6 43.7 Smoking                     Current16.616.215.015.0 7.48.78.49.1 20.420.118.718.6Former31.631.831.633.3 39.238.139.039.8 28.729.328.930.6Never51.852.053.451.7 53.453.252.651.1 50.950.652.550.8Amount of Sleep                 Less than 6 hours-15.215.513.5 -8.912.612.4 -18.817.614.66 hours-21.921.520.5 -21.519.218.1 -23.722.822.37-8 hours-55.453.254.9 -60.855.453.0 -51.351.254.89 hours or more-7.69.811.1 -8.812.816.5 -6.28.48.3Self-Reported Special Diet                 Low Fat/Low Cholesterol-3.52.82.4 -3.83.32.8 -2.92.52.1Low Salt/Low Sodium-2.53.53.6 -3.14.75.3 -2.63.63.1Sugar Free/Low Sugar-2.01.10.4 -2.51.50.3 -1.61.10.5Diabetic Diet-6.65.25.1 -6.85.46.9 -7.45.25.5Renal Diet--0.30.6 --0.71.2 --0.50.8Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate.

18 vol 1 Figure 1.9 NHANES participants physically active, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate.

19 vol 1 Table 1.5 Awareness, treatment, & measures of control of CKD risk factors, percentage of NHANES participants, 1999-2014   All CKD   eGFR <60 ml/min/1.73m 2   ACR ≥30 mg/g   1999-2002 2003-2006 2007-2010 2011-2014 Trend p-value   1999-2002 2003-2006 2007-2010 2011-2014 Trend p-value   1999-2002 2003-2006 2007-2010 2011-2014 Trend p-valueHypertension, by current hypertensive statusa             Non-hypertensive status26.925.826.826.10.87 14.814.615.617.00.20 29.730.331.128.60.75Hypertensive (measured/treated)73.174.273.273.9 85.285.484.483.0 70.369.768.971.5Control of hypertension among hypertensive patientsb                       Unaware64.325.419.522.6<0.001 58.121.017.013.1<0.001 67.726.824.723.0<0.001Aware, not treated5.68.49.75.8 3.25.22.54.3 6.610.38.212.6Aware, treated, uncontrolled 22.146.642.343.8 26.651.445.545.8 21.146.344.943.9Aware, treated, controlled8.019.628.527.8 12.122.435.036.8 4.716.522.120.5Total cholesterolc                 <200 (desirable)43.253.159.261.6<0.001 40.756.662.664.3<0.001 44.952.858.261.3<0.001200–239 (borderline high)35.327.526.324.1 37.025.823.522.0 34.227.727.224.8240+ (high)21.519.414.514.4 22.317.613.913.7 20.919.514.613.9Control of diabetes among patients with diabetesd              Glycohemoglobin <7% (controlled)32.851.146.942.90.20 45.662.555.949.30.57 28.845.340.136.80.37Glycohemoglobin 7% or higher (uncontrolled)67.248.953.157.1 54.437.544.150.7 71.254.759.963.2Data Source: National Health and Nutrition Examination Survey (NHANES), 1999–2002, 2003-2006, 2007-2010 & 2011–2014 participants age 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate. a. Hypertension defined as blood pressure ≥130/≥80 for those with CKD and diabetes; otherwise ≥140/≥90, or self- reported treatment for hypertension. b. Awareness and treatment are self-reported. Control defined as <130/<80 for those with CKD and diabetes; otherwise <140/<90. c. Total cholesterol classified according to Adult Treatment Panel III blood cholesterol guidelines (ATP III). d. Glycohemoglobin classified according to American Diabetes Association guidelines.

20 vol 1 Figure 1.10 NHANES participants at target blood pressure, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Figure represents all hypertensive participants including those who were at target blood pressure, probably due to medication. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate.

21 vol 1 Figure 1.11 NHANES participants within cholesterol normal range, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate.

22 vol 1 Figure 1.12 Diabetic NHANES participants with glycosylated hemoglobin <7%, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 1999-2002, 2003-2006, 2007-2010 & 2011–2014 participants aged 20 & older. Single-sample estimates of eGFR & ACR; eGFR calculated using the CKD-EPI equation. Abbreviations: ACR, urine albumin/creatinine ratio; CKD, chronic kidney disease; eGFR , estimated glomerular filtration rate.

23 vol 1 Figure 1.13 NHANES participants with CKD aware of their kidney disease, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 2001-2012 participants aged 20 & older. Abbreviations: CKD, chronic kidney disease. (a) By stage

24 vol 1 Figure 1.13 NHANES participants with CKD aware of their kidney disease, 1999-2014 Data Source: National Health and Nutrition Examination Survey (NHANES), 2001-2012 participants aged 20 & older. Abbreviations: CKD, chronic kidney disease. (b) By low eGFR and albuminuria status

25 vol 1 Figure 1.14 Estimated prevalence of self-reported kidney disease by state, BRFSS participants ages 18 and older Data source: Behavioral Risk Factors Surveillance System (BRFSS), 2012 participants aged 18 & older. 2012 (N=471,107), 2013 (N=491,777), 2014 (N=464,617), and 2015 (N=441,460). (a) 2012

26 vol 1 Figure 1.14 Estimated prevalence of self-reported kidney disease by state, BRFSS participants ages 18 and older Data source: Behavioral Risk Factors Surveillance System (BRFSS), 2012 participants aged 18 & older. 2012 (N=471,107), 2013 (N=491,777), 2014 (N=464,617), and 2015 (N=441,460). (b) 2013

27 vol 1 Figure 1.14 Estimated prevalence of self-reported kidney disease by state, BRFSS participants ages 18 and older Data source: Behavioral Risk Factors Surveillance System (BRFSS), 2012 participants aged 18 & older. 2012 (N=471,107), 2013 (N=491,777), 2014 (N=464,617), and 2015 (N=441,460). (c) 2014

28 vol 1 Figure 1.14 Estimated prevalence of self-reported kidney disease by state, BRFSS participants ages 18 and older Data source: Behavioral Risk Factors Surveillance System (BRFSS), 2012 participants aged 18 & older. 2012 (N=471,107), 2013 (N=491,777), 2014 (N=464,617), and 2015 (N=441,460). (d) 2015