Seasonal Variations in Transition, Mortality, and Kidney Transplantation among Patients with End-Stage Renal Disease in the United States Yoshitsugu Obi, Kamyar Kalantar-Zadeh, Elani Streja, Connie M. Rhee, Uttam G. Reddy, Melissa Soohoo, Yaping Wang, Vanessa Ravel, Amy S. You, Jennie Jing, John J. Sim, Danh V. Nguyen, Daniel L. Gillen, Rajiv Saran, Bruce Robinson, and Csaba P. Kovesdy Nephrol Dial Transpl . 2017 in press https://www.ncbi.nlm.nih.gov/pubmed/28201764
Obi Y, Kalantar-Zadeh K, Streja E, …, and Kovesdy CP. Seasonal Variations in Transition, Mortality, and Kidney Transplantation among Patients with End-Stage Renal Disease in the United States. Nephrol Dial Transplant. 2017 in press . Background: Seasonal variations may exist in transitioning to dialysis, kidney transplantation, and related outcomes among end-stage-renal-disease (ESRD) patients. Elucidating these variations may have major clinical and health care policy implications for better resource allocation across seasons . Methods: Using the United States Renal Data System (USRDS) database from 1/1/2000 to 12/31/2013 , we calculated monthly counts of transitioning to dialysis or first transplantation and deaths. Crude monthly transition fraction was defined as the number of new ESRD patients divided by all ESRD patients on the first day of each month. Similar fractions were calculated for all-cause and cause-specific mortality and transplantation.
Characteristics on January 1 st and the annual events of each year among patients with ESRD in the U.S. (2000 – 2013) Patient characteristics on January 1st of each year Event frequencies in each year Year ≥65 yrs (%) Total ESRD Total Dialysis Age (year) Female (%) Blacks (%) Diabetes (%) Transition Death KTx 56.0 ± 16.6 2000 373,091 278,897 34% 45% 32% 34% 103,958 (28%) 71,122 (19%) 14,625 (4%) 56.3 ± 16.5 2001 394,136 294,395 35% 45% 32% 35% 107,750 (27%) 75,215 (19%) 15,261 (4%) 56.5 ± 16.4 2002 414,259 308,674 35% 45% 32% 36% 110,092 (27%) 77,736 (19%) 15,767 (4%) 56.8 ± 16.4 2003 433,912 322,108 35% 45% 32% 36% 112,073 (26%) 80,630 (19%) 16,090 (4%) 57.0 ± 16.3 2004 452,357 334,822 35% 45% 31% 36% 113,699 (25%) 82,090 (18%) 16,920 (4%) 57.3 ± 16.3 2005 470,963 346,660 35% 44% 31% 36% 116,609 (25%) 83,461 (18%) 17,427 (4%) 57.5 ± 16.2 2006 490,153 358,858 35% 44% 31% 37% 120,300 (25%) 85,123 (17%) 18,031 (4%) 57.7 ± 16.1 2007 511,143 372,719 36% 44% 31% 37% 120,496 (24%) 85,079 (17%) 17,504 (3%) 57.9 ± 16.0 2008 531,685 386,419 36% 44% 31% 37% 121,913 (23%) 85,601 (16%) 17,383 (3%) 58.1 ± 15.9 2009 553,086 401,124 36% 44% 31% 37% 125,571 (23%) 87,108 (16%) 17,671 (3%) 58.4 ± 15.8 2010 576,003 417,651 37% 43% 31% 37% 126,118 (22%) 87,675 (15%) 17,728 (3%) 58.6 ± 15.8 2011 598,722 434,052 37% 43% 31% 37% 123,798 (21%) 88,536 (15%) 17,584 (3%) 58.8 ± 15.7 2012 618,857 447,908 38% 43% 31% 37% 126,264 (20%) 86,722 (14%) 17,250 (3%) 59.1 ± 15.6 2013 642,020 465,404 38% 43% 31% 37% 117,372 (18%) 86,781 (14%) 17,605 (3%) KTx, kidney transplantation Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
Consistent seasonal variation in transition to ESRD, all-cause death, and KTx irrespective of secular trends . (Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT 2017 in press .) Normalized monthly counts Transition to ESRD KTx 12,000 3,000 All-cause death 10,000 2,500 8,000 2,000 6,000 1,500 4,000 1,000 2,000 500 Transition to ESRD (Left axis) All-cause death (Left axis) KTx (Right axis) 0 0 Jan-00 Sep-00 May-01 Jan-02 Sep-02 May-03 Jan-04 Sep-04 May-05 Jan-06 Sep-06 May-07 Jan-08 Sep-08 May-09 Jan-10 Sep-10 May-11 Jan-12 Sep-12 May-13 Transition to ESRD Normalized monthly fractions KTx 2.50 0.75 All-cause death 2.00 0.60 1.50 0.45 1.00 0.30 0.50 0.15 Transition to ESRD (Left axis) All-cause death (Left axis) KTx (Right axis) 0.00 0.00 Jan-00 Aug-00 Mar-01 Oct-01 May-02 Dec-02 Jul-03 Feb-04 Sep-04 Apr-05 Nov-05 Jun-06 Jan-07 Aug-07 Mar-08 Oct-08 May-09 Dec-09 Jul-10 Feb-11 Sep-11 Apr-12 Nov-12 Jun-13 Monthly fractions = #Events in the month / #ESRD Pts on the 1 st day of the month
Monthly transition to ESRD was lowest in July and highest in January. For each year 14-year average 2.4 2.4 2000 2.2 2.2 2001 2002 2003 2 2 2004 2005 2006 1.8 1.8 2007 2008 1.6 1.6 2009 2010 2011 1.4 1.4 2012 2013 1.2 1.2 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Monthly fractions = #Events in the month / #ESRD Pts on the 1 st day of the month Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
The seasonal variation in transition to ESRD was mainly attributed to HD, not PD. Number of new ESRD (HD) Number of new ESRD (PD) 9000 1000 8000 800 7000 600 6000 5000 400 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
All-cause mortalities was lowest in August and highest in January. 1.9 1.9 For each year 14-year average 1.8 1.8 2000 2001 1.7 1.7 2002 1.6 1.6 2003 2004 1.5 1.5 2005 2006 1.4 1.4 2007 1.3 1.3 2008 2009 1.2 1.2 2010 1.1 1.1 2011 2012 1 1 2013 0.9 0.9 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Monthly fractions = #Events in the month / #ESRD Pts on the 1 st day of the month Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
The seasonal variation in all-cause death was consistent between HD vs. PD. Number of all-cause death (HD) Number of all-cause death (PD) 6500 500 6000 450 5500 400 5000 350 4500 300 4000 250 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
The seasonal variation in mortality was consistent between CV vs. infectious death. Cardiovascular mortality fraction (Total) Infectious mortality fraction (Total) 1.0 0.25 0.8 0.15 0.6 0.4 0.05 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
Kidney transplantation was highest in June and lowest in December. For each year 14-year average 0.36 0.36 2000 2001 2002 0.32 0.32 2003 2004 2005 2006 0.28 0.28 2007 2008 2009 2010 0.24 0.24 2011 2012 2013 0.2 0.2 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Monthly fractions = #Events in the month / #KTx recipients on the 1 st day of the month Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
The seasonal variation in KTx was mainly attributed to living donors, not cadaveric donors. Number of living KTx Number of cadaveric KTx 700 1200 650 1000 600 550 800 500 600 450 400 400 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
Kidney transplant failure was highest in January and lowest in September. KTx failure fraction 0.8 0.7 0.6 0.5 0.4 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
Conclusions • The 14-year cumulative data from the USRDS (2000-2013) showed consistent seasonal variations in the transition to ESRD, and all-cause, cardiovascular, and infectious deaths, as well as kidney transplantation and transplant failure. • We found strikingly robust pattern of seasonal variation in that adverse events and transitioning to ESRD were more frequent in winter and less frequent in summer. • Understanding these variations may allow for more efficient and cost-effective allocation of health care resources across seasons of the years, and have subsequent impact upon clinical practice and health care policy. Obi Y, Kalantar-Zadeh K, Streja E, …, Kovesdy CP. NDT . 2017 in press .
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