Original Investigation
Pathogenesis and Treatment of Kidney Disease
Prevalence of CKD in the United States: A Sensitivity Analysis Using the National Health and Nutrition Examination Survey (NHANES) 1999-2004

https://doi.org/10.1053/j.ajkd.2008.07.034Get rights and content

Background

Estimates of chronic kidney disease (CKD) in the United States using the continuous National Health and Nutrition Examination Survey (NHANES) data set 1999-2004 indicate that 13.1% of the population (26.3 million people based on the 2000 census) has CKD stages 1 to 4.

Study Design

We performed sensitivity analyses to highlight assumptions underlying these estimates and illustrate their robustness to varying assumptions.

Setting & Participants

NHANES 1999-2004 was a nationally representative cross-sectional continuous survey of the civilian noninstitutionalized US population. Our sample included participants 20 years and older.

Reference Test

Estimated glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 defined from the 4-variable Modification of Diet in Renal Disease (MDRD) Study equation; albuminuria defined as persistence of urinary albumin-creatinine ratio greater than 30 mg/g.

Index Tests

We compared prevalence estimates using the MDRD Study equation with 2 other GFR estimating equations (equation 5 by Rule et al from the Mayo Clinic Donors study; Cockcroft-Gault equation adjusted for body surface area and corrected for the bias in the MDRD Study sample), and sex-specific cutoff values to define albuminuria.

Results

We found CKD stages 1 to 4 prevalence estimates ranging from 11.7% to 24.9%, a more than 2-fold difference resulting in population estimates of 25.8 million to 54.0 million people using 2006 population estimates. Considering only stages 3 and 4, which are not affected by the choice of cutoff values to define albuminuria, prevalence estimates ranged from 6.3% to 18.6%, resulting in population estimates of 13.7 million to 40.3 million people, a nearly 3-fold difference.

Limitations

NHANES 1999-2004 is a cross-sectional survey and allows for GFR and albumin-creatinine ratio estimates at 1 point in time. NHANES does not account for seniors in long-term care facilities.

Conclusions

Although CKD prevalence is high regardless of varying modeling assumptions, different assumptions yield large differences in prevalence estimates.

Section snippets

Methods

The prevalence of CKD stages 1 to 4 was assessed by using data from the continuous NHANES 1999-2004. From 1999 to 2004, the National Center for Health Statistics used NHANES to continually monitor the health of the US population. NHANES uses a complex multistage probability sampling design to assess the health of a nationally representative sample of the civilian noninstitutionalized US population. The National Center for Health Statistics releases data from NHANES in 2-year intervals. This

Results

Age, sex, and race data were present for all 14,213 participants included in the analysis. Serum creatinine values were missing for 939 participants (6.6%), and urinary albumin or creatinine values, for 424 (3.0%). Thus, GFR was estimated using the MDRD Study equation or Mayo equation for 13,274 participants (93.4%). Body surface area values were missing for 502 participants (3.5%). Thus, GFR was estimated using the Cockcroft-Gault equation for 12,895 participants (90.7%).

Table 4 lists

Discussion

Results of this analysis show how varying assumptions can affect CKD prevalence estimates using continuous NHANES 1999-2004 data. At one end of the spectrum of assumptions, an estimated 25.8 million people 20 years and older in the United States have CKD stages 1 to 4. At the other end of the spectrum, an additional 28.2 million people, or 54.0 million total, have CKD.

The largest difference in estimated prevalence is caused by using differing GFR estimating equations. The MDRD Study equation is

Acknowledgements

The authors thank Aaron R. Folsom, MD, MPH; David R. Jacobs, PhD; Richard H. Grimm, MD, PhD; David T. Gilbertson, PhD; and Eric D. Weinhandl, MS, for guidance; US Renal Data System colleagues Beth Forrest, BBA, and Shane Nygaard, BA, for manuscript preparation; and Nan Booth, MSW, MPH, for manuscript editing.

Support: This study was performed as a deliverable under Contract No. HHSN267200715002C (National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health,

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    Originally published online as doi:10.1053/j.ajkd.2008.07.034 on October 28, 2008.

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