BACKGROUND: Simultaneous urine testing for albumin (UAlb) and serum creatinine (SCr), that is, 'dual testing,' is an accepted quality measure in the management of diabetes. As chronic kidney disease (CKD) is defined by both UAlb and SCr testing, this approach could be more widely adopted in kidney care. OBJECTIVE: We assessed time trends and facility-level variation in the performance of outpatient dual testing in the integrated Veterans Health Administration (VHA) system. DESIGN, SUBJECTS AND MAIN MEASURES: This retrospective cohort study included patients with any inpatient or outpatient visit to the VHA system during the period 2009-2018. Dual testing was defined as UAlb and SCr testing in the outpatient setting within a calendar year. We assessed time trends in dual testing by demographics, comorbidities, high-risk (eg, diabetes) specialty care and facilities. A generalised linear mixed-effects model was applied to explore individual and facility-level predictors of receiving dual testing. KEY RESULTS: We analysed data from approximately 6.9 million veterans per year. Dual testing increased, on average, from 17.4% to 21.2%, but varied substantially among VHA centres (0.3%-43.7% in 2018). Dual testing was strongly associated with diabetes (OR 10.4, 95% CI 10.3 to 10.5, p<0.0001) and not associated with VHA centre complexity level. However, among patients with high-risk conditions including diabetes, <50% received dual testing in any given year. As compared with white veterans, black veterans were less likely to be tested after adjusting for other individual and facility characteristics (OR 0.93, 95% CI 0.92 to 0.93, p<0.0001). CONCLUSIONS: Dual testing for CKD in high-risk specialties is increasing but remains low. This appears primarily due to low rates of testing for albuminuria. Promoting dual testing in high-risk patients will help to improve disease management and patient outcomes.

BACKGROUND: Inflammation may affect long-term kidney function. Diet may play a role in chronic inflammation. We hypothesized that proinflammatory diets increase the risk of progression to kidney failure with replacement therapy (KFRT), and systemic inflammation is a mediator of the effect of diet on progression to KFRT. METHODS: In the 1988-1994 National Health and Nutrition Examination Survey linked to the national ESKD registry, in adults with CKD (eGFR 15-59 ml/min per 1.73 m(2)), aged ≥20 years, we calculated the Adapted Dietary Inflammatory Index (ADII) at baseline from a 24-hour dietary recall and an inflammation score (IS) using average of z scores of four inflammation biomarkers. We explored the association of the ADII and IS with risk of incident KFRT using Cox proportional model, adjusting for sociodemographics, physical activity, Framingham risk score, eGFR, and urinary ACR. We evaluated whether, and to what extent, IS mediated the effect of the ADII on KFRT incidence, using causal mediation analysis. RESULTS: Of 1084 adults with CKD, 109 (10%) developed KFRT. The ADII was associated with increased risk of KFRT (relative hazard [RH] per SD increase (2.56): 1.4 [1.04-1.78]). IS was also associated with KFRT (RH: 1.12; 95% CI, 1.02 to 1.25). Approximately 36% of the association between the ADII and KFRT was explained by IS. CONCLUSIONS: Among adults with CKD, a proinflammatory diet was associated with risk of KFRT, and that association was partially explained by an increase in inflammatory markers. Dietary interventions that reduce inflammation may offer an approach for preventing KFRT.

INTRODUCTION: Mortality is an important long-term indicator of the public health impact of chronic kidney disease (CKD). We investigated the role of individual comorbidities and multimorbidity on age-specific mortality risk among US veterans with new-onset CKD. METHODS: The cohort included 892,005 veterans aged 18 years with incident CKD stage 3 between January 2004 and April 2018 in the US Veterans Health Administration (VHA) system and followed until death, December 2018, or up to 10 years. Incident CKD was defined as the first-time estimated glomerular filtration rate (eGFR) was <60 mL/min/1.73 m2 for >3 months. Comorbidities were ascertained using inpatient and outpatient clinical records in the VHA system and Medicare claims. We estimated death rates for any cardiovascular disease (CVD, a composite of 6 CVD conditions) and 15 non-CVD comorbidities, and adjusted risks of death (hazard ratio [HR], 95% confidence interval [CI]) overall and by age group at CKD incidence. RESULTS: At CKD incidence, the mean age was 72 years, and 97% were male; the mean eGFR was 52 mL/min/1.73 m2, and 95% had 2 comorbidities (median, 4) in addition to CKD. During a median follow-up of 4.5 years, among the 16 comorbidities, CVD was associated with the highest relative risk of death in younger veterans (HR 1.96 [95% CI: 1.61-2.37] in ages 18-44 years and HR 1.66 [1.63-1.70] in ages 45-64 years). Dementia was associated with the highest relative risk of death among older veterans (HR 1.71 [1.68-1.74] in ages 65-84 years and HR 1.69 [1.65-1.73] in ages 85-100 years). The additive effect of multimorbidity on risk of death was stronger in younger than older veterans. Compared to having 1 or no comorbidity at CKD onset, the risk of death with 5 comorbidities was >7-fold higher among veterans aged 18-44 years and >2-fold higher among veterans aged 85-100 years. CONCLUSION: The large burden of comorbidities in US veterans with newly identified CKD places them at the risk of premature death. Compared with older veterans, younger veterans with multiple comorbidities, particularly with CVD, at CKD onset are at an even higher relative risk of death.

RATIONALE & OBJECTIVE: The US Military Health System (MHS) is a global health care network with a diverse population that is more representative of the US population than other study cohorts and with fewer disparities in health care access. We aimed to examine the prevalence of chronic kidney disease (CKD) in the MHS and within demographic subpopulations. STUDY DESIGN: Multiple cross-sectional analyses of demographic and claims-based data extracted from the MHS Data Repository, 1 for each fiscal year from 2006-2015. SETTING & POPULATION: Multicenter health care network including active-duty military, retirees, and dependents. The average yearly sample size was 3,285,348 individuals. EXPOSURES: Age, sex, race, active-duty status, and active-duty rank (a surrogate for socioeconomic status). OUTCOME: CKD, defined as the presence of matching International Classification of Diseases, Ninth Revision, codes on either 1 or more inpatient or 2 or more outpatient encounters. ANALYTICAL APPROACH: t test for continuous variables and χ(2) test for categorical variables; multivariable logistic regression for odds ratios. RESULTS: For 2015, the mean (standard deviation) age was 38 (16). Crude CKD prevalence was 2.9%. Age-adjusted prevalence was 4.9% overall-1.9% active-duty and 5.4% non-active-duty individuals. ORs for CKD were calculated with multiple imputations to account for missing data on race. After adjustment, the ORs for CKD (all P < 0.001) were 1.63 (95% CI, 1.62-1.64) for an age greater than 40 years, 1.16 (95% CI, 1.15-1.17) for Black race, 1.15 (95% CI, 1.14-1.16) for senior enlisted rank, 0.94 (95% CI, 0.93-0.95) for women, and 0.50 (95% CI, 0.49-0.51) for active-duty status. LIMITATIONS: Retrospective study based on International Classification of Diseases, Ninth Revision, coding. CONCLUSIONS: Within the MHS, older age, Black race, and senior enlisted rank were associated with a higher risk of CKD, whereas female sex and active-duty status were associated with a lower risk.

End-stage kidney disease (ESKD) (kidney failure requiring dialysis or transplantation) is a costly and disabling condition that often results in premature death (1). During 2019, Medicare fee-for-service expenditures for ESKD were $37.3 billion, accounting for approximately 7% of Medicare paid claims costs (1). Diabetes and hypertension remain the leading causes of ESKD, accounting for 47% and 29%, respectively, of patients who began ESKD treatment in 2019 (1). Compared with White persons, Black, Hispanic, and American Indian or Alaska Native persons are more likely to develop ESKD (1,2) and to have diagnosed diabetes (3). After declining for more than a decade, the incidence rate of ESKD with diabetes reported as the primary cause (ESKD from diabetes) has leveled off since 2010 (1,4). Further, after increasing for many years, the prevalence of diagnosed diabetes has also leveled off (4). Although these flattening trends in rates are important from a population perspective, the trend in the number of ESKD cases is important from a health systems resources perspective. Using United States Renal Data System (USRDS) 2000-2019 data, CDC examined trends in the number of incident and prevalent ESKD cases by demographic characteristics and by primary cause of ESKD. During 2000-2019, the number of incident ESKD cases increased by 41.8%, and the number of prevalent ESKD cases increased by 118.7%. Higher percentage changes in both incident and prevalent ESKD cases were among Asian, Hispanic, and Native Hawaiian or other Pacific Islander persons and among cases with hypertension or diabetes as the primary cause. Interventions to improve care and better manage ESKD risk factors among persons with diabetes and hypertension, along with increased use of therapeutic agents such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin-receptor blockers (ARB), and sodium-glucose cotransporter 2 (SGLT2) inhibitors shown to have kidney-protective benefits (5,6) might slow the increase and eventually reverse the trend in incident ESKD cases.

BACKGROUND AND OBJECTIVES: AKI, a frequent complication among hospitalized patients, confers excess short- and long-term mortality. We sought to determine trends in in-hospital and 1-year mortality associated with AKI as defined by Kidney Disease Improving Global Outcomes consensus criteria. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This retrospective cohort study used data from the national Veterans Health Administration on all patients hospitalized from October 1, 2008 to September 31, 2017. AKI was defined by Kidney Disease Improving Global Outcomes serum creatinine criteria. In-hospital and 1-year mortality trends were analyzed in patients with and without AKI using Cox regression with year as a continuous variable. RESULTS: We identified 1,688,457 patients and 2,689,093 hospitalizations across the study period. Among patients with AKI, 6% died in hospital, and 28% died within 1 year. In contrast, in-hospital and 1-year mortality rates were 0.8% and 14%, respectively, among non-AKI hospitalizations. During the study period, there was a slight decline in crude in-hospital AKI-associated mortality (hazard ratio, 0.98 per year; 95% confidence interval, 0.98 to 0.99) that was attenuated after accounting for patient demographics, comorbid conditions, and acute hospitalization characteristics (adjusted hazard ratio, 0.99 per year; 95% confidence interval, 0.99 to 1.00). This stable temporal trend in mortality persisted at 1 year (adjusted hazard ratio, 1.00 per year; 95% confidence interval, 0.99 to 1.00). CONCLUSIONS: AKI associated mortality remains high, as greater than one in four patients with AKI died within 1 year of hospitalization. Over the past decade, there seems to have been no significant progress toward improving in-hospital or long-term AKI survivorship.

IMPORTANCE: Significant racial and ethnic disparities in chronic kidney disease (CKD) progression and outcomes are well documented, as is low use of guideline-recommended CKD care. OBJECTIVE: To examine guideline-recommended CKD care delivery by race and ethnicity in a large, diverse population. DESIGN, SETTING, AND PARTICIPANTS: In this serial cross-sectional study, adult patients with CKD that did not require dialysis, defined as a persistent estimated glomerular filtration rate less than 60 mL/min/1.73 m2 or a urine albumin-creatinine ratio of 30 mg/g or higher for at least 90 days, were identified in 2-year cross-sections from January 1, 2012, to December 31, 2019. Data from the OptumLabs Data Warehouse, a national data set of administrative and electronic health record data for commercially insured and Medicare Advantage patients, were used. EXPOSURES: The independent variables were race and ethnicity, as reported in linked electronic health records. MAIN OUTCOMES AND MEASURES: On the basis of guideline-recommended CKD care, the study examined care delivery process measures (angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker prescription for albuminuria, statin prescription, albuminuria testing, nephrology care for CKD stage 4 or higher, and avoidance of chronic nonsteroidal anti-inflammatory drug prescription) and care delivery outcome measures (blood pressure and diabetes control). RESULTS: A total of 452 238 patients met the inclusion criteria (mean [SD] age, 74.0 [10.2] years; 262 089 [58.0%] female; a total of 7573 [1.7%] Asian, 49 970 [11.0%] Black, 15 540 [3.4%] Hispanic, and 379 155 [83.8%] White). Performance on process measures was higher among Asian, Black, and Hispanic patients compared with White patients for angiotensin-converting enzyme inhibitor and angiotensin II receptor blocker use (79.8% for Asian patients, 76.7% for Black patients, and 79.9% for Hispanic patients compared with 72.3% for White patients in 2018-2019), statin use (72.6% for Asian patients, 69.1% for Black patients, and 74.1% for Hispanic patients compared with 61.5% for White patients), nephrology care (64.8% for Asian patients, 72.9% for Black patients, and 69.4% for Hispanic patients compared with 58.3% for White patients), and albuminuria testing (53.9% for Asian patients, 41.0% for Black patients, and 52.6% for Hispanic patients compared with 30.7% for White patients). Achievement of blood pressure control to less than 140/90 mm Hg was similar or lower among Asian (71.8%), Black (63.3%), and Hispanic (69.8%) patients compared with White patients (72.9%). Achievement of diabetes control with hemoglobin A1c less than 7.0% was 50.1% in Asian patients, 49.3% in Black patients, and 46.0% in Hispanic patients compared with 50.3% for White patients. CONCLUSIONS AND RELEVANCE: Higher performance on CKD care process measures among Asian, Black, and Hispanic patients suggests that differences in medication prescription and diagnostic testing are unlikely to fully explain known disparities in CKD progression and kidney failure. Improving care delivery processes alone may be inadequate for reducing these disparities.

BACKGROUND: The association between fruit and vegetable (FV) intake and the risk of end-stage kidney disease (ESKD) has not been examined in the general population and fully explored in chronic kidney disease (CKD). We prospectively evaluated this relationship in US representative sample of adults and evaluated consistency by the presence or absence, and severity, of CKD. METHODS: We used data from the Third National Health and Nutrition Examination Survey (1988-1994) linked with the US Renal Data System, including 14,725 adults aged ≥20 years and with follow-up for ESKD through 2008. Daily FV intake was ascertained using a food frequency questionnaire. We examined the association between selected categories of FV intake and ESKD using a Fine Gray competing risk model adjusting for sociodemographics, lifestyle, clinical and nutritional factors, estimated glomerular filtration rate, and albuminuria. We evaluated whether risk varied in individuals with severe versus any CKD. RESULTS: 230 participants (1.5%) developed ESKD during follow-up. In the adjusted model, compared to highest intake, those in lowest categories of FV intake had a higher risk of ESKD, for <2 times/day (1.45 [1.24-1.68], 2 to <3 times/day (1.40 [1.18-1.61]), 3 to <4 times/day (1.25 [1.04-1.46]), and 4 to <6 times/day (1.14 [0.97-1.31]). There was suggestion of heterogeneity (p for interaction = 0.03) with possible stronger inverse association in patients with CKD than those without CKD. After stratification, we obtained similar strong inverse association when we examined ESKD incidence across intake of FVs in participants with CKD stages 1-4 (n = 5,346) and specifically in those with CKD stages 3-4 (n = 1,084). CONCLUSIONS: Low intake of FVs was associated with higher risk of ESKD in US adults with and without CKD, supporting an emerging body of literature on the potential benefits of plant-rich diets for prevention of ESKD.

INTRODUCTION: Little is known about the role diabetes (type 1 (T1D) and type 2 (T2D)) plays in modifying prognosis among kidney transplant recipients. Here, we compare mortality among transplant recipients with T1D, T2D and non-diabetes-related end-stage kidney disease (ESKD). RESEARCH DESIGN AND METHODS: We included 254 188 first-time single kidney transplant recipients aged ≥18 years from the US Renal Data System (2000-2018). Diabetes status, as primary cause of ESKD, was defined using International Classification of Disease 9th and 10th Clinical Modification codes. Multivariable-adjusted Cox regression models (right-censored) computed risk of death associated with T1D and T2D relative to non-diabetes. Trends in standardized mortality ratios (SMRs) (2000-2017), relative to the general US population, were assessed using Joinpoint regression. RESULTS: A total of 72 175 (28.4%) deaths occurred over a median survival time of 14.6 years. 5-year survival probabilities were 88%, 85% and 77% for non-diabetes, T1D and T2D, respectively. In adjusted models, mortality was highest for T1D (HR=1.95, (95% CI: 1.88 to 2.03)) and then T2D (1.65 (1.62 to 1.69)), as compared with non-diabetes. SMRs declined for non-diabetes, T1D, and T2D. However, in 2017, SMRs were 2.38 (2.31 to 2.45), 6.55 (6.07 to 7.06), and 3.82 (3.68 to 3.98), for non-diabetes, T1D and T2D, respectively. CONCLUSIONS: In the USA, diabetes type is an important modifier in mortality risk among kidney transplant recipients with highest rates among people with T1D-related ESKD. Development of effective interventions that reduce excess mortality in transplant recipients with diabetes is needed, especially for T1D.

For almost two decades, equations that use serum creatinine, age, sex, and race to eGFR have included "race" as Black or non-Black. Given considerable evidence of disparities in health and healthcare delivery in African American communities, some regard keeping a race term in GFR equations as a practice that differentially influences access to care and kidney transplantation. Others assert that race captures important GFR determinants and its removal from the calculation may perpetuate other disparities. The National Kidney Foundation (NKF) and American Society of Nephrology (ASN) established a task force in 2020 to reassess the inclusion of race in the estimation of GFR in the United States and its implications for diagnosis and subsequent management of patients with, orat risk for, kidney diseases.This interim report details the process, initial assessment of evidence, and values defined regarding the use of race to estimate GFR. We organized activities in phases: (1) clarify the problem and examine evidence, (2) evaluate different approaches to address use of race in GFR estimation, and (3) make recommendations. In phase one, we constructed statements about the evidence and defined values regarding equity and disparities; race and racism; GFR measurement, estimation, and equation performance; laboratory standardization; and patient perspectives. We also identified several approaches to estimate GFR and a set of attributes to evaluate these approaches. Building on evidence and values, the attributes of alternative approaches to estimate GFR will be evaluated in the next phases and recommendations will be made.

BACKGROUND: To better understand the relation between sleep problems and CKD, we examined temporal trends in the prevalence of self-reported sleep problems in adults in the United States and their associations with CKD and all-cause mortality. METHODS: Using data from 27,365 adult participants in five biannual National Health and Examination Surveys (2005-2006 through 2013-2014), we studied five self-reported sleep problems-trouble sleeping, sleep disorder, nocturia (urinating ≥2 times/night), inadequate sleep (<7 hours/night), and excessive sleep (>9 hours/night)-plus a composite index. We conducted three types of analysis: temporal trends in the prevalence of each sleep measure by CKD status, using model-based standardization; cross-sectional analysis of associations between four CKD measures and each sleep measure, using logistic regression; and survival analysis of the association between each sleep measure and mortality, using Cox regression. RESULTS: The prevalence of trouble sleeping and sleep disorder increased over the five surveys by 4% and 3%, respectively, whereas the other sleep problems remained relatively stable. All sleep problems, except inadequate sleep, were more common during the study period among adults with CKD than without CKD (40% versus 21% for nocturia; 5% versus 2% for excessive sleep; 30% versus 25% for trouble sleeping; 12% versus 8% for sleep disorder). Both eGFR <30 ml/min per 1.73 m(2) and albuminuria were positively associated with nocturia and excessive sleep. Excessive sleep and nocturia were also associated with higher mortality (adjusted hazard ratio for >9 versus 7-9 hours/night=1.7; 95% CI, 1.3 to 2.1; and for nocturia=1.2; 95% CI, 1.1 to 1.4). CONCLUSIONS: The high prevalence of sleep problems among persons with CKD and their associations with mortality suggest their potential importance to clinical practice. Future work could examine the health effects of identifying and treating sleep problems in patients with CKD.

BACKGROUND: There is considerable state-level variation in the incidence of dialysis-requiring acute kidney injury (AKI-D). However, little is known about reasons for this geographic variation. METHODS: National cross-sectional state-level ecological study based on State Inpatient Databases (SID) and the Behavioral Risk Factor Surveillance System (BRFSS) in 2011. We analyzed 18 states and six chronic health conditions (diabetes mellitus [diabetes], hypertension, chronic kidney disease [CKD], arteriosclerotic heart disease [ASHD], cancer (excluding skin cancer), and chronic obstructive pulmonary disease [COPD]). Associations between each of the chronic health conditions and AKI-D incidence was assessed using Pearson correlation and multiple regression adjusting for mean age, the proportion of males, and the proportion of non-Hispanic whites in each state. RESULTS: The state-level AKI-D incidence ranged from 190 to 1139 per million population. State-level differences in rates of hospitalization with chronic health conditions (mostly < 3-fold difference in range) were larger than the state-level differences in prevalence for each chronic health condition (mostly < 2.5-fold difference in range). A significant correlation was shown between AKI-D incidence and prevalence of diabetes, ASHD, and COPD, as well as between AKI-D incidence and rate of hospitalization with hypertension. In regression models, after adjusting for age, sex, and race, AKI-D incidence was associated with prevalence of and rates of hospitalization with five chronic health conditions--diabetes, hypertension, CKD, ASHD and COPD--and rates of hospitalization with cancer. CONCLUSIONS: Results from this ecological analysis suggest that state-level variation in AKI-D incidence may be influenced by state-level variations in prevalence of and rates of hospitalization with several chronic health conditions. For most of the explored chronic conditions, AKI-D correlated stronger with rates of hospitalizations with the health conditions rather than with their prevalences, suggesting that better disease management strategies that prevent hospitalizations may translate into lower incidence of AKI-D.

INTRODUCTION: The objective of this study was to examine recent trends in diagnosed diabetes prevalence for American Indian and Alaska Native (AI/AN) adults aged 18 years and older in the Indian Health Service (IHS) active clinical population. RESEARCH DESIGN AND METHODS: Data were extracted from the IHS National Data Warehouse for AI/AN adults for each fiscal year from 2006 (n=729 470) through 2017 (n=1 034 814). The prevalence of diagnosed diabetes for each year and the annual percentage change were estimated for adults overall, as well as by sex, age group, and geographic region. RESULTS: After increasing significantly from 2006 to 2013, diabetes prevalence for AI/AN adults in the IHS active clinical population decreased significantly from 2013 to 2017. Prevalence was 14.4% (95% CI 13.9% to 15.0%) in 2006; 15.4% (95% CI 14.8% to 16.0%) in 2013; and 14.6% (95% CI 14.1% to 15.2%) in 2017. Trends for men and women were similar to the overall population, as were those for all age groups. For all geographic regions, prevalence either decreased significantly or leveled off in recent years. CONCLUSIONS: Diabetes prevalence in AI/AN adults in the IHS active clinical population has decreased significantly since 2013. While these results cannot be generalized to all AI/AN adults in the USA, this study documents the first known decrease in diabetes prevalence for AI/AN people.

RATIONALE & OBJECTIVE: Persons with chronic kidney disease (CKD) are often unaware of their disease status. Efforts to improve CKD awareness may be most effective if focused on persons at highest risk for progression to kidney failure. STUDY DESIGN: Serial cross-sectional surveys. SETTING & PARTICIPANTS: Nonpregnant adults (aged>/=20 years) with CKD glomerular filtration rate categories 3-4 (G3-G4) who participated in the National Health and Nutrition Examination Survey from 1999 to 2016 (n = 3,713). PREDICTOR: 5-year kidney failure risk, estimated using the Kidney Failure Risk Equation. Predicted risk was categorized as minimal (<2%), low (2%-<5%), intermediate (5%-<15%), or high (>/=15%). OUTCOME: CKD awareness, defined by answering "yes" to the question "Have you ever been told by a doctor or other health professional that you had weak or failing kidneys?" ANALYTICAL APPROACH: Prevalence of CKD awareness was estimated within each risk group using complex sample survey methods. Associations between Kidney Failure Risk Equation risk and CKD awareness were assessed using multivariable logistic regression. CKD awareness was compared with awareness of hypertension and diabetes during the same period. RESULTS: In 2011 to 2016, unadjusted CKD awareness was 9.6%, 22.6%, 44.7%, and 49.0% in the minimal-, low-, intermediate-, and high-risk groups, respectively. In adjusted analyses, these proportions did not change over time. Awareness of CKD, including among the highest risk group, remains consistently below that of hypertension and diabetes and awareness of these conditions increased over time. LIMITATIONS: Imperfect sensitivity of the "weak or failing kidneys" question for ascertaining CKD awareness. CONCLUSIONS: Among adults with CKD G3-G4 who have 5-year estimated risks for kidney failure of 5%-<15% and>/=15%, approximately half were unaware of their kidney disease, a gap that has persisted nearly 2 decades.

RATIONALE & OBJECTIVE: Dialysis-requiring acute kidney injury (AKI-D) has increased substantially in the United States. We examined trends in and comorbid conditions associated with hospitalizations and in-hospital mortality in the setting of AKI-D among people with versus without diabetes. STUDY DESIGN: Cross-sectional study. SETTING & PARTICIPANTS: Nationally representative data from the National Inpatient Sample and National Health Interview Survey were used to generate 16 cross-sectional samples of US adults (aged >/=18 years) between 2000 and 2015. EXPOSURE: Diabetes, defined using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. OUTCOME: AKI-D, defined using ICD-9-CM diagnosis and procedure codes. ANALYTICAL APPROACH: Annual age-standardized rates of AKI-D and AKI-D mortality were calculated for adults with and without diabetes, by age and sex. Data were weighted to be representative of the US noninstitutionalized population. Trends were assessed using join point regression with annual percent change (Delta/y) reported. RESULTS: In adults with diabetes, AKI-D increased between 2000 and 2015 (from 26.4 to 41.1 per 100,000 persons; Delta/y, 3.3%; P < 0.001), with relative increases greater in younger versus older adults. In adults without diabetes, AKI-D increased between 2000 and 2009 (from 4.8 to 8.7; Delta/y, 6.5%; P < 0.001) and then plateaued. AKI-D mortality significantly declined in people with and without diabetes. In adults with and without diabetes, the proportion of AKI-D hospitalizations with liver, rheumatic, and kidney disease comorbid conditions increased between 2000 and 2015, while the proportion of most cardiovascular comorbid conditions decreased. LIMITATIONS: Lack of laboratory data to corroborate AKI diagnosis; National Inpatient Sample data are hospital-level rather than person-level data; no data for type of diabetes; residual unmeasured confounding. CONCLUSIONS: Hospitalization rates for AKI-D have increased considerably while mortality has decreased in adults with and without diabetes. Hospitalization rates for AKI-D remain substantially higher in adults with diabetes. Greater AKI risk-factor mitigation is needed, especially in young adults with diabetes.

AIMS/HYPOTHESIS: Cancer-related death is higher among people with vs without diabetes. However, it is not known if this excess risk has changed over time or what types of cancer may be driving these changes. METHODS: To estimate rates of site-specific cancer mortality in adults with vs without self-reported diagnosed diabetes, we used data from adults aged >/=18 years at the time of the interview who participated in the 1985-2012 National Health Interview Survey. Participants' data were linked to the National Death Index by the National Center for Health Statistics to determine vital status and cause of death through to the end of 2015. Cancer deaths were classified according to underlying cause of death. Death rates for five time periods (1988-1994, 1995-1999, 2000-2004, 2005-2009, 2010-2015) were estimated using discrete Poisson regression models adjusted for age, sex and race/ethnicity with p for linear trend reported (ptrend). Site-specific cancer mortality rates were stratified by diabetes status and period, and total cancer mortality rates were additionally stratified by sex, race/ethnicity, education and BMI status. RESULTS: Among adults with diabetes, age-adjusted cancer mortality rates (per 10,000 person-years) declined 25.5% from 39.1 (95% CI 30.1, 50.8) in 1988-1994 to 29.7 (26.6, 33.1) in 2010-2015, ptrend < 0.001. Among adults without diabetes, rates declined 25.2% from 30.9 (28.6, 33.4) in 1988-1994 to 23.2 (22.1, 24.2) in 2010-2015, ptrend < 0.01. Adults with diabetes remained approximately 30% more likely to die from cancer than people without diabetes, and this excess risk did not improve over time. In adults with diabetes, cancer mortality rates did not decline in some population subgroups (including black people, people with lower levels of education and obese people), and the excess risk increased for obese adults with vs without diabetes. Declines in total cancer mortality rates in adults with diabetes appear to be driven by large relative declines in cancers of the pancreas (55%) and breast (65%), while for lung cancer, declines are modest (7%). CONCLUSIONS/INTERPRETATION: Declines in cancer mortality rates were observed in adults with and without diabetes. However, adults with diabetes continue to be more likely to die from cancer than people without diabetes. This study highlights the continued need for greater cancer risk-factor mitigation, especially in adults with diabetes.

BACKGROUND: Approximately 4-6% of incident end stage renal disease (ESRD) patients in the U.S. recover enough kidney function to discontinue dialysis but there is considerable geographic variation. We undertook this study to investigate whether state-level variations in renal recovery among incident ESRD patients correlated with state-level variations in incidence of acute kidney injury requiring dialysis (AKI-D). METHODS: We conducted a national cross-sectional ecological study at the state-level using data from State Inpatient Databases and U.S. Renal Data System. All hospital admissions and all ESRD patients in 18 US states (AZ, AR, CA, FL, IA, KY, MA, MD, MI, NJ, NM, NY, NV, OR, RI, SC, VT, and WA) were included. Correlation between AKI-D incidence and rate of renal recovery across states was determined using Pearson's r (overall and in subgroups). We also calculated partial correlations adjusted for sex and age. RESULTS: AKI-D incidence ranged from 99.0 per million population (pmp) in Vermont to 490.4 pmp in Nevada. Rate of renal recovery among incident ESRD patients ranged from 8.8 pmp in Massachusetts to 29.3 pmp in Florida. A positive correlation between AKI-D incidence and rate of renal recovery among incident ESRD patients at state level was found overall (unadjusted r = 0.67; p = 0.002) and in age, sex, and race subgroups. The overall correlation persisted after adjusting for age (adjusted r = 0.62; p < 0.001) and sex (adjusted r = 0.65; p < 0.001). CONCLUSION: Our findings suggest that AKI-D incidence is an important driver of renal recovery rates among incident ESRD patients.

OBJECTIVE: Nontraumatic lower-extremity amputation (NLEA) is a complication of end-stage renal disease (ESRD) and diabetes. Although recent data show that NLEA rates in the U.S. ESRD population are declining overall, trends in diabetes and diabetes subgroups remain unclear. RESEARCH DESIGN AND METHODS: We estimated annual rates of NLEA hospitalizations during 2000-2015 among >2 million adults (>/=18 years) with ESRD from the U.S. Renal Data System. Age, sex, and race-adjusted NLEA rates were stratified by diabetes status, age, sex, race, and level of amputation (toe, foot, below the knee, and above the knee). Time trends were assessed using Joinpoint regression with annual percent changes (APC) reported. RESULTS: Among adults with diabetes, NLEA rates declined 43.8% between 2000 and 2013 (from 7.5 to 4.2 per 100 person-years; APC -4.9, P < 0.001) and then stabilized. Among adults without diabetes, rates of total NLEAs declined 25.5% between 2000 and 2013 (from 1.6 to 1.1; APC -3.0, P < 0.001) and then stabilized. These trends appear to be driven by a slowing or stagnation in declines of minor NLEAs (toe and foot) in more recent years, while major NLEAs (above the knee) continue to decline. CONCLUSIONS: Despite an initial period of decline, this analysis documents a stall in progress in NLEA trends in recent years in a high-risk population with both ESRD and diabetes. Increased attention to preventive foot care in the ESRD population should be considered, particularly for those with diabetes.

The Dietary Approaches to Stop Hypertension (DASH) diet lowers blood pressure, an important risk factor for chronic kidney disease (CKD) and end-stage renal disease (ESRD). However, it is unclear whether adherence to a DASH diet confers protection against future ESRD, especially among those with pre-existing CKD and hypertension. We examined whether a DASH diet is associated with lower risk of ESRD among 1,110 adults aged >/= 20 years with hypertension and CKD (estimated glomerular filtration rate, eGFR 30-59 ml/min/1.73 m(2)) enrolled in the National Health and Nutrition Examination Survey (1988-1994). Baseline DASH diet accordance score was assessed using a 24-hour dietary recall questionnaire. ESRD was ascertained by linkage to the U.S. Renal Data System registry. We used the Fine-Gray competing risks method to estimate the relative hazard (RH) for ESRD after adjusting for sociodemographics, clinical and nutritional factors, eGFR, and albuminuria. Over a median follow-up of 7.8 years, 18.4% of subjects developed ESRD. Compared to the highest quintile of DASH diet accordance, there was a greater risk of ESRD among subjects in quintiles 1 (RH=1.7; 95% CI 1.1-2.7) and 2 (RH 2.2; 95% CI 1.1-4.1). Significant interactions were observed with diabetes status and race/ethnicity, with the strongest association between DASH diet adherence and ESRD risk observed in individuals with diabetes and in non-Hispanic blacks. Low accordance to a DASH diet is associated with greater risk of ESRD in adults with moderate CKD and hypertension, particularly in non-Hispanic blacks and persons with diabetes.

BACKGROUND: Most people with chronic kidney disease (CKD) are not aware of their condition. OBJECTIVES: To assess screening criteria in identifying a population with or at high risk for CKD and to determine their level of control of CKD risk factors. METHOD: CKD Health Evaluation Risk Information Sharing (CHERISH), a demonstration project of the Centers for Disease Control and Prevention, hosted screenings at 2 community locations in each of 4 states. People with diabetes, hypertension, or aged >/=50 years were eligible to participate. In addition to CKD, screening included testing and measures of hemoglobin A1C, blood pressure, and lipids. -Results: In this targeted population, among 894 people screened, CKD prevalence was 34%. Of participants with diabetes, 61% had A1C < 7%; of those with hypertension, 23% had blood pressure < 130/80 mm Hg; and of those with high cholesterol, 22% had low-density lipoprotein < 100 mg/dL. CONCLUSIONS: Using targeted selection criteria and simple clinical measures, CHERISH successfully identified a population with a high CKD prevalence and with poor control of CKD risk factors. CHERISH may prove helpful to state and local programs in implementing CKD detection programs in their communities.

As noted by de Miguel-Yanes et al. (1), we reported a decline in hospitalization rates from 1998 to 2014 for several cardiovascular disease (CVD) conditions in the U.S. population with diabetes (2). Similar to their report on cardiovascular events in people with diabetes in Spain (3), we found that during the study period hospitalization rates for acute coronary syndrome decreased in the U.S. population with diabetes. In seeming contrast with their findings, we reported in this population overall significant declines in hospitalization rates for ischemic stroke and hemorrhagic stroke. However, consistent with their findings and of particular concern, we noted in the latter part of the period increases in hospitalization rates for ischemic stroke in several subgroups, including those aged 35–74 years, men, women, non-Hispanic whites, and non-Hispanic blacks. Although specific reasons for the observed heterogeneity in our study cannot be determined from surveillance data, shifting patterns of case finding or declines in diabetes incidence (4) and decreases in mortality (5) in the U.S. may be changing the epidemiologic characteristics of the U.S. population with diabetes to a more high-risk population susceptible to the development of diabetes complications. More years of data and continued surveillance of CVD hospitalizations in the U.S. population with diabetes will be needed to confirm these trends. | | Furthermore, as de Miguel-Yanes et al (1) pointed out, differences in the impact of treatment, preventive treatment, or risk factor control between populations of different countries may account for differences in CVD trends.

BACKGROUND AND OBJECTIVES: Whether patients with monoclonal protein are at a higher risk for progression of kidney disease is not known. The goal of this study was to measure the association of monoclonal protein with progression to ESKD. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: This was a retrospective cohort study of 2,156,317 patients who underwent serum creatinine testing between October 1, 2000 and September 30, 2001 at a Department of Veterans Affairs medical center, among whom 21,898 had paraprotein testing within 1 year before or after cohort entry. Progression to ESKD was measured using linked data from the US Renal Data System. RESULTS: Overall, 1,741,707 cohort members had an eGFR>/=60 ml/min per 1.73 m(2), 283,988 had an eGFR of 45-59 ml/min per 1.73 m(2), 103,123 had an eGFR of 30-44 ml/min per 1.73 m(2) and 27,499 had an eGFR of 15-29 ml/min per 1.73 m(2). The crude incidence of ESKD ranged from 0.7 to 80 per 1000 person-years from the highest to lowest eGFR category. Patients with low versus preserved eGFR were more likely to be tested for monoclonal protein but no more likely to have a positive test result. In adjusted analyses, a positive versus negative test result was associated with a higher risk of ESKD among patients with an eGFR>/=60 ml/min per 1.73 m(2) (hazard ratio, 1.67; 95% confidence interval, 1.22 to 2.29) and those with an eGFR of 15-29 ml/min per 1.73 m(2) (hazard ratio, 1.38; 95% confidence interval, 1.07 to 1.77), but not among those with an eGFR of 30-59 ml/min per 1.73 m(2) . Progression to ESKD was attributed to a monoclonal process in 21 out of 76 versus seven out of 174 patients with monoclonal protein and preserved versus severely reduced eGFR at cohort entry. CONCLUSIONS: The detection of monoclonal protein provides little information on ESKD risk for most patients with a low eGFR. Further study is required to better understand factors contributing to a positive association of monoclonal protein with ESKD risk in patients with preserved and severely reduced levels of eGFR.

RATIONALE & OBJECTIVE: As the prevalence of obesity continues to rise in the United States, it is important to understand its impact on the lifetime risk of chronic kidney disease (CKD). STUDY DESIGN: The CKD Health Policy Model was used to simulate the lifetime risk of CKD for those with and without obesity at baseline. Model structure was updated for glomerular filtration rate (GFR) decline to incorporate new longitudinal data from the Chronic Renal Insufficiency Cohort (CRIC) study. SETTING AND POPULATION: The updated model was populated with a nationally representative cohort from National Health and Nutrition Examination Survey (NHANES). OUTCOMES: Lifetime risk of CKD, highest stage and any stage. MODEL, PERSPECTIVE, & TIMEFRAME: Simulation model following up individuals from current age through death or age 90 years. RESULTS: Lifetime risk of any CKD stage was 32.5% (95% CI 28.6%-36.3%) for persons with normal weight, 37.6% (95% CI 33.5%-41.7%) for persons who were overweight, and 41.0% (95% CI 36.7%-45.3%) for persons with obesity at baseline. The difference between persons with normal weight and persons with obesity at baseline was statistically significant (p<0.01). Lifetime risk of CKD stages 4 and 5 was higher for persons with obesity at baseline (Stage 4: 2.1%, 95% CI 0.9%-3.3%; stage 5: 0.6%, 95% CI 0.0%-1.1%), but the differences were not statistically significant (stage 4: p = 0.08; stage 5: p = 0.23). LIMITATIONS: Due to limited data, our simulation model estimates are based on assumptions about the causal pathways from obesity to CKD, diabetes, and hypertension. CONCLUSIONS: The results of this study indicate that obesity may have a large impact on the lifetime risk of CKD. This is important information for policymakers seeking to set priorities and targets for CKD prevention and treatment.

RATIONALE & OBJECTIVE: Albuminuria and low estimated glomerular filtration rate (eGFR) define chronic kidney disease in adults and youth. Different from adults, the burden of abnormal kidney markers among youth in the general United States population is largely unknown. STUDY DESIGN: Serial cross-sectional national surveys. SETTING & PARTICIPANTS: Adolescents aged 12 to 18 years participating in the National Health and Nutrition Examination Surveys 1988 to 2014. Surveys were grouped into three 6-year periods. PREDICTORS: Demographic and clinical determinants of kidney markers. OUTCOME: Prevalence and trends in persistent albuminuria, low (< 60mL/min/1.73m(2)) and reduced (< 90mL/min/1.73m(2)) eGFRs. ANALYTICAL APPROACH: Outcomes defined as persistent albumin-creatinine ratio >/= 30mg/g (persistent albuminuria), eGFR < 90mL/min/1.73m(2) (reduced kidney function), and eGFR < 60mL/min/1.73m(2) (low kidney function). Multiple imputation analysis was used to estimate missing follow-up values of albuminuria. RESULTS: Prevalences of persistent albuminuria were 3.64% (95% CI, 1.82%-5.46%) in 1988-1994 and 3.29% (95% CI, 1.94%-4.63%) in 2009-2014 (adjusted prevalence ratio, 0.93; 95% CI, 0.53-1.62; P=0.8 for trend). Prevalences of reduced eGFR were 31.46% (95% CI, 28.42%-34.67%) and 34.58% (95% CI, 32.07%-37.18%), respectively (adjusted prevalence ratio, 1.21; 95% CI, 1.00-1.46; P < 0.001 for trend). Prevalences of low eGFR were 0.32% (95% CI, 0.12%-0.84%) in 1988-1994 and 0.91% (95% CI, 0.58%-1.42%) in 2009-2014 (adjusted prevalence ratio, 3.10; 95% CI, 1.10-9.01; P = 0.09 for trend). Prevalences of albuminuria and/or low eGFR remained at 4.0% in 1988-1994 and 2009-2014 (adjusted prevalence ratio, 1.06; 95% CI, 0.64-1.77; P = 0.8 for trend). LIMITATIONS: Persistent albuminuria data were based on imputed values (for second assessment of albuminuria) in 91% of participants; lack of second eGFR assessment to confirm sustained reduction in kidney function. CONCLUSIONS: Albuminuria prevalence has not changed significantly in the US adolescent population between 1988 and 2014. Prevalences of both reduced and low eGFRs were higher in the most recent study period; however, < 1% of adolescents had low eGFRs.

BACKGROUND: Dietary acid load (DAL) contributes to the risk of CKD and CKD progression. We sought to determine the relation of DAL to racial/ethnic differences in the risk of end-stage renal disease (ESRD) among persons with CKD. METHODS: Among 1,123 non-Hispanic black (NHB) and non-Hispanic white (NHW) National Health and Nutrition Examination Survey III participants with estimated glomerular filtration rate 15-59 mL/min/1.73 m2, DAL was estimated using the Remer and Manz net acid excretion (NAEes) formula and 24-h dietary recall. ESRD events were ascertained via linkage with Medicare. A competing risk model (accounting for death) was used to estimate the hazard ratio (HR) for treated ESRD, comparing NHBs with NHWs, adjusting for demographic, clinical and nutritional factors (body surface area, total caloric intake, serum bicarbonate, protein intake), and NAEes. Additionally, whether the relation of NAEes with ESRD risk varied by race/ethnicity was tested. RESULTS: At baseline, NHBs had greater NAEes (50.9 vs. 44.2 mEq/day) than NHWs. It was found that 22% developed ESRD over a median of 7.5 years. The unadjusted HR comparing NHBs to NHWs was 3.35 (95% CI 2.51-4.48) and adjusted HR (for factors above) was 1.68 (95% CI 1.18-2.38). A stronger association of NAE with risk of ESRD was observed among NHBs (adjusted HR per mEq/day increase in NAE 1.21, 95% CI 1.12-1.31) than that among NHWs (HR 1.08, 95% CI 0.96-1.20), p interaction for race/ethnicity x NAEes = 0.004. CONCLUSIONS: Among US adults with CKD, the association of DAL with progression to ESRD is stronger among NHBs than NHWs. DAL is worthy of further investigation for its contribution to kidney outcomes across race/ethnic groups.

Acute kidney injury is a sudden decrease in kidney function with or without kidney damage, occurring over a few hours or days. Diabetes, hypertension, and advanced age are primary risk factors for acute kidney injury. It is increasingly recognized as an in-hospital complication of sepsis, heart conditions, and surgery (1,2). Its most severe stage requires treatment with dialysis. Acute kidney injury is also associated with higher likelihood of long-term care, incidence of chronic kidney disease and hospital mortality, and health care costs (1,2). Although a number of U.S. studies have indicated an increasing incidence of dialysis-treated acute kidney injury since the late 1990s (3), no data are available on national trends in diabetes-related acute kidney injury. To estimate diabetes- and nondiabetes-related acute kidney injury trends, CDC analyzed 2000-2014 data from the National Inpatient Sample (NIS) (4) and the National Health Interview Survey (NHIS) (5). Age-standardized rates of acute kidney injury hospitalizations increased by 139% (from 23.1 to 55.3 per 1,000 persons) among adults with diagnosed diabetes, and by 230% (from 3.5 to 11.7 per 1,000 persons) among those without diabetes. Improving both patient and provider awareness that diabetes, hypertension, and advancing age are frequently associated with acute kidney injury might reduce its occurrence and improve management of the underlying diseases in an aging population.

OBJECTIVE: Reductions in heart attack and stroke hospitalizations are well documented in the U.S. population with diabetes. We extended trend analyses to other cardiovascular disease (CVD) conditions, including stroke by type, and used four additional years of data. RESEARCH DESIGN AND METHODS: Using 1998-2014 National (Nationwide) Inpatient Sample data, we estimated the number of discharges having acute coronary syndrome (ACS) (ICD-9 codes 410-411), cardiac dysrhythmia (427), heart failure (428), hemorrhagic stroke (430-432), or ischemic stroke (433.x1, 434, and 436) as first-listed diagnosis and diabetes (250) as secondary diagnosis. Hospitalization rates for adults aged ≥35 years were calculated using estimates from the population with and the population without diabetes from the National Health Interview Survey and age-adjusted to the 2000 U.S. standard population. Joinpoint regression was used to analyze trends and calculate an average annual percentage change (AAPC) with 95% confidence limits (CLs). RESULTS: From 1998 to 2014, in the population with diabetes, age-adjusted hospitalization rates declined significantly for ACS (AAPC -4.6% per year [95% CL -5.3, -3.8]), cardiac dysrhythmia (-0.7% [-1.1, -0.2]), heart failure (-3.6% [-4.6, -2.7]), hemorrhagic stroke (-1.1% [-1.4, -0.7]), and ischemic stroke (-2.9% [-3.9, -1.8]). In the population without diabetes, rates also declined significantly for these conditions, with the exception of dysrhythmia. By 2014, rates in the population with diabetes population remained two to four times as high as those for the population without diabetes, with the largest difference in heart failure rates. CONCLUSIONS: CVD hospitalization rates declined significantly in both the population with diabetes and the population without diabetes. This may be due to several factors, including new or more aggressive treatments and reductions in CVD risk factors and CVD incidence.

During 2014, 120,000 persons in the United States and Puerto Rico began treatment for end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation) (1). Among these persons, 44% (approximately 53,000 persons) had diabetes listed as the primary cause of ESRD (ESRD-D) (1). Although the number of persons initiating ESRD-D treatment each year has increased since 1980 (1,2), the ESRD-D incidence rate among persons with diagnosed diabetes has declined since the mid-1990s (2,3). To determine whether ESRD-D incidence has continued to decline in the United States overall and in each state, the District of Columbia (DC), and Puerto Rico, CDC analyzed 2000-2014 data from the U.S. Renal Data System and the Behavioral Risk Factor Surveillance System. During that period, the age-standardized ESRD-D incidence among persons with diagnosed diabetes declined from 260.2 to 173.9 per 100,000 diabetic population (33%), and declined significantly in most states, DC, and Puerto Rico. No state experienced an increase in ESRD-D incidence rates. Continued awareness of risk factors for kidney failure and interventions to improve diabetes care might sustain and improve these trends.

INTRODUCTION: This study examined state-level variation in chronic kidney disease (CKD) awareness using national estimates of disease awareness among adults in the U.S. with CKD. METHODS: Data on U.S. adults were obtained from two national, population-based surveys: (1) the Behavioral Risk Factor Surveillance System (BRFSS 2011; n=506,467), a state-level phone survey containing information on self-reported kidney disease; and (2) the National Health and Nutrition Examination Survey (NHANES 2005-2012; n=20,831), containing physical health examination, surveys containing data on self-reported kidney disease, risk factors, and laboratory values. CKD was defined as an estimated glomerular filtration rate of 15-59 mL/minute/1.73 m2 or urinary albumin-to-creatinine ratio >30 mg/g. As BRFSS does not include laboratory data, CKD status for each person was imputed (multiple) based on a logistic regression model predicting NHANES CKD status. CKD awareness in each state was estimated as the weighted proportion of BRFSS participants with imputed CKD who reported having kidney disease. RESULTS: Overall, estimated CKD awareness was 9.0% (95% CI=8.0%, 10.0%), ranging from 5.8% (95% CI=4.8%, 6.8%) in Iowa to 11.7% (95% CI=9.7%, 13.7%) in Arizona. Awareness was greater among adults with hypertension (12.0%) and diabetes (15.3%) than among adults without those conditions, and lower in Hispanics (6.0%) than in non-Hispanic whites (8.8%), non-Hispanic blacks (9.9%), and other racial/ethnic groups (12.7%). CONCLUSIONS: Among individuals with CKD, awareness of their condition was very low and varied approximately twofold among states. This is the first study to estimate awareness of kidney disease by state for the U.S. adult population.

The American Society of Nephrology recommends against routine cancer screening among asymptomatic patients receiving maintenance dialysis on the basis of limited survival benefit. To determine the frequency of colorectal cancer screening among patients on dialysis and the extent to which screening tests were targeted toward patients at lower risk of death and higher likelihood of receiving a kidney transplant, we performed a cohort study of 469,574 Medicare beneficiaries ages ≥50 years old who received dialysis between January 1, 2007 and September 30, 2012. We examined colorectal cancer screening tests according to quartiles of risk of mortality and kidney transplant on the basis of multivariable Cox modeling. Over a median follow-up of 1.5 years, 11.6% of patients received a colon cancer screening test (57.9 tests per 1000 person-years). Incidence rates of colonoscopy, flexible sigmoidoscopy, and fecal occult blood test were 27.9, 0.6, and 29.5 per 1000 person-years, respectively. Patients in the lowest quartile of mortality risk were more likely to be screened than those in the highest quartile (hazard ratio, 1.53; 95% confidence interval, 1.49 to 1.57; 65.1 versus 46.4 tests per 1000 person-years, respectively), amounting to a 33% higher rate of testing. Additionally, compared with patients least likely to receive a transplant, patients most likely to receive a transplant were more likely to be screened (hazard ratio, 1.68; 95% confidence interval, 1.64 to 1.73). Colon cancer screening is being targeted toward patients on dialysis at lowest risk of mortality and highest likelihood of transplantation, but absolute rates are high, suggesting overscreening.