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Background and Objectives: Data are limited regarding BP distribution and the prevalence of hypertension in pediatric long-term dialysis patients. This study aimed to examine BP distribution in U.S. pediatric long-term hemodialysis patients., Design, Setting, Participants, & Measurements: This cross-sectional study of all U.S. pediatric (aged 0-< 18 yr, n = 624) long-term hemodialysis patients was performed as part of the Centers for Medicare & Medicaid Services End-Stage Renal Disease (ESRD) Clinical Performance Measures Project. BP and clinical information were collected monthly in October, November, and December 2001. Hypertension was defined as the mean of pre- and postdialysis systolic or diastolic BP above the 95th percentile for age, height, and sex, or antihypertensive medication use. Results were calculated by age, sex, race, ethnicity, ESRD duration, body mass index percentile, primary cause of ESRD, and laboratory data., Results: Hypertension was present in 79% of patients; 62% used antihypertensive medication. Five percent of patients were prehypertensive (mean BP at 90th to 95th percentile). Hypertension was uncontrolled in 74% of treated patients. Characteristics associated with hypertension included acquired kidney disease, shorter duration of ESRD, and lower mean hemoglobin and calcium values. Characteristics associated with uncontrolled hypertension were younger age and shorter duration of ESRD., Conclusions: Hypertension is common in U.S. pediatric long-term hemodialysis patients, uncontrolled in 74% of treated patients, and untreated in 21% of hypertensive patients. It is concluded that a more aggressive approach to treatment of hypertension is warranted in pediatric long-term hemodialysis patients.

Background: A proportion of haemodialysis patients experience periods below target haemoglobin levels due to longer time required to reach the target or to haemoglobin level variability. We aimed to determine the consequences associated with cumulative number of months below target haemoglobin concentrations., Methods: We constructed an incident cohort including patients whose day 91 after dialysis initiation fell between 1 January and 31 December 2002. Haemoglobin concentration, erythropoiesis-stimulating agent dose, comorbid condition and hospitalization data were obtained from Medicare claims. Patients were classified by 0, 1, 2 or 3 months with haemoglobin concentration below the K/DOQI target (11 g/dL). Using an inverse probability weighted marginal structural model to adjust for time-varying factors associated with haemoglobin concentration, we determined the association between number of months below target and subsequent risk for hospitalization and mortality., Results: The final cohort included 54 328 patients who met criteria. Those with more months below haemoglobin target were less likely to have received intravenous iron. More months below target were associated with increased risk of hospitalization (RR 1.70, 95% CI 1.63-1.76) and mortality (RR 2.48, 95% CI 2.28-2.69)., Conclusions: Future interventions should focus on modifiable factors associated with greater time below target haemoglobin concentrations to determine whether altering the time below target can alter the risk of hospitalizations or mortality.

While hospitalization is common for hemodialysis patients, perihospitalization associations between hemoglobin levels and epoetin doses are not well characterized. U.S. Medicare claims were used to identify 71,360 hemodialysis patients hospitalized from 1998 to 2003. Hemoglobin levels, epoetin doses, and epoetin responsiveness index (ERI) were compared by calendar year. In the prehospitalization month, the mean hemoglobin levels increased from 10.96 g/dL in 1998 to 11.76 in 2003 and the mean epoetin doses from 63,715 to 75,012 U; corresponding values in the hospitalization month were 10.53 and 11.19 g/dL, and 66,623 and 80,569 U. In each year, prehospitalization hemoglobin levels were achieved within 2 months, but ERI declined to prehospitalization levels within 12 months only in 2000. With mixed models, hemoglobin declines in the 3 prehospitalization months grew between 1998 (-0.1362 g/dL/month) and 2003 (-0.2003 g/dL/month). Epoetin responsiveness index slopes were J-shaped, with values of 287.9, 221.1, and 356.5U/month per g/dL in 1998, 2000, and 2003. In the 3 postadmission months, a modest increase in the rapidity of hemoglobin recovery was seen (+0.2538 g/dL/month in 1998, +0.2743 in 2003), with increasing rates of ERI change (+8.7 U/month/g/dL in 1998, +146.8 in 2003). While time to recovery of prehospitalization hemoglobin levels remained constant year to year, epoetin doses and ERI did not, suggesting that optimum perihospitalization anemia management practices have yet to be determined.

Patients with failed renal transplants represent an increasing proportion of the current dialysis population. Although their risk of anemia might be expected to be high, whether these patients receive adequate anemia therapy after returning to dialysis is unknown. We studied intravenous iron use, epoetin doses, and hemoglobin levels in patients with and without failed renal transplants who survived for 6 months after initiation of dialysis in the United States between 1996 and 2001. Of the study population (n=220 557), 9922 (4.5%) had failed renal transplants. In spite of a greater likelihood of receiving intravenous iron therapy (adjusted odds ratio (AOR) 1.47, P<0.0001) and epoetin (AOR 1.57, P<0.0001), patients with failed transplants were more anemic and had higher epoetin doses in each month of follow-up. During month 6, patients with failed transplants were more likely to have hemoglobin levels below 11 g/dl (AOR 1.50, P<0.0001) and to have epoetin-to-hemoglobin ratios above the population median of 1030 U/week per g/dl (AOR 1.73, P<0.0001). Patients who return to dialysis with failed transplants are at a higher risk of anemia than other patients who start dialysis; the pattern of lower hemoglobin levels and higher ratios of epoetin-to-hemoglobin suggests that relative epoetin resistance may be contributory.

Infection is a common cause of morbidity and mortality in patients with ESRD. Infection-related hospitalization (IH) incidence among US Medicare incident pediatric and adult dialysis and transplant patients within 3 yr of presentation was compared from 1996 to 2001: Hemodialysis (HD) patients (pediatric n = 1469; adult n = 305,323); peritoneal dialysis (PD) patients (pediatric n=982; adult n=27,119), and kidney transplant (KTx) patients (pediatric n=1108; adult n=31,663). IH were identified from principal diagnosis codes; IH cumulative incidence and rates were calculated from claims data. Cumulative incidence of IH at 36 mo for incident pediatric patients with ESRD during 1996 to 2001 was 39.9% in HD, 51.2% in PD, and 47.4% in KTx patients (HD or PD versus KTx, P<0.0001). Cumulative incidence for adults was 52.6% in HD, 51.8% in PD, and 39.8% in KTx patients (HD or PD versus KTx, P<0.0001). IH rates per 1000 patient-months were highest for pediatric KTx patients (adjusted rate ratio 1.53 versus HD and 1.90 versus PD, P<0.001 for each) and adult HD patients (adjusted rate ratio 1.20 versus KTx and 1.11 versus PD, P < 0.001 for each). Within the first 36 mo of incidence, IH rates are highest for incident pediatric KTx patients compared with HD and PD patients, in contrast to findings for adult patients with ESRD. Pediatric KTx patients require infection surveillance after transplantation.

The objective of this study was to examine the total cost to Medicare associated with the presence of anemia in congestive heart failure (CHF) patients. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify anemia, CHF, and comorbid conditions in 2002, and total Medicare costs were calculated for 2003. The mean patient age was 77.8 years. Anemia, present in 32% of CHF patients, was associated with older age, female sex, non-white race, and increasing burden of comorbidity. The total per-member-per-month cost in 2003 was $1781.01 among CHF patients with anemia in the preceding year compared with $1142.38 for CHF patients without anemia, a ratio of 1.56 (95% confidence interval, 1.5589-1.5592). When adjustment was made for baseline demographic factors and comorbid conditions, the corresponding ratio was 1.25 (95% confidence interval, 1.2546-1.2548). Anemia, a common association of CHF in elderly patients, is an antecedent association of increased societal medical expenditure.

The size of the prevalent ESRD population in the United States increased dramatically during the 1990s, from 196,000 in 1991 to 382,000 in 2000. Incidence also increased considerably during the same period, from 53,000 to 93,000 per year. If previous trends in ESRD incidence and prevalence continue, then current levels of health care resources that are devoted to the care of these patients will eventually be unable to meet the demand. This study discusses a Markov model developed to predict ESRD incidence, prevalence, and mortality to the year 2015 and incorporating expected changes in age/race distributions, diabetes prevalence, ESRD incidence, and probability of death. The model predicted that by 2015 there will be 136,166 incident ESRD patients per year (lower/upper limits 110,989 to 164,550), 712,290 prevalent patients (595,046 to 842,761), and 107,760 ESRD deaths annually (96,068 to 118,220). Incidence and prevalence counts are expected to increase by 44 and 85%, respectively, from 2000 to 2015 and incidence and prevalence rates per million population by 32 and 70%, respectively. The financial and human resources that will be needed to care for these patients in 2015 will be considerably greater than in 2005.

Background: Anemia is associated with disease severity and prognosis for patients with congestive heart failure (CHF). It is unknown whether anemia is associated with the development of new-onset CHF in the elderly., Methods and Results: This retrospective longitudinal cohort study used the Medicare 5% database. In the incident analysis, the study sample comprised subjects without CHF in 1999 (n = 1,063,495); the main exposure variable evaluated was the presence or absence of anemia in 1999; and the primary study outcome was the occurrence of new-onset CHF. The prevalence of chronic anemia and CHF in 1999 was 5.0% and 9.9%, respectively. The incidence of new-onset CHF in 2000 in those with and those without anemia in 1999 was 12.3% and 5.9%, respectively, corresponding to an adjusted hazard ratio of 1.29 ( P < .001), a value intermediate between the hazard ratios of 1.13 ( P < .001), and 1.76 ( P < .001) associated with hypertension and atherosclerotic heart disease, respectively. Anemia also was associated with death in the year after new-onset CHF (adjusted hazard ratio, 1.28; P < .001)., Conclusion: Anemia in the Medicare population is associated with the diagnosis and prognosis of new-onset CHF.