1. Chapter 8: Transition of Care in Chronic Kidney Disease 2015 A NNUAL D ATA R EPORT V OLUME 1: C HRONIC K IDNEY D ISEASE

2. Data source: VHA Administrative data, USRDS ESRD Database. States and territories of the United States of America. Abbreviations: ESRD, end-stage renal disease. Figure 8.1 Distribution of preemptive kidney transplant rates among 52,172 incident ESRD veterans across the states and territories of the United States, 10/1/2007-9/30/2011 Vol 1, CKD, Ch 82

3. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data, U.S. Census Bureau; data derived from U.S. veteran incident dialysis patients. a Veterans to U.S. rate ratios. Abbreviations: ESRD, end- stage renal disease; PM; per million; Vet, veterans. Table 8.1 Rates and ratios of incident ESRD among veterans and in U.S. adults, 10/1/2007-9/30/2011 Vol 1, CKD, Ch 83 55-64 years65-74 years75 years or older 200820092010200820092010200820092010 Incident ESRD veterans 318032923115305431873080592457875740 All veterans 571830254417395340529414857241523314294221491101248516714839173 ESRD rate in veterans, per million 556605583736768717120611931186 ESRD rate in the U.S., per million 7737787521297131127654515591582 ESRD rate ratio (Vet: U.S.) a 0.720.78 0.570.590.560.780.760.75

4. Data source: USRDS ESRD Database. Table adapted from the 2014 USRDS Annual Data Report. a Uncertain groups have no know dialysis modality, b n for outcomes is cumulative for subsequent periods after Day 1. Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; CCPD, continuous cycling peritoneal dialysis; ESRD, end-stage renal disease; HD hemodialysis. Table 8.2 Status of 52,172 incident ESRD veterans on Day 1 and Day 90 after transition to ESRD, 10/1/2007-9/30/2011 Vol 1, CKD, Ch 84 Day 1Day 90 n%n% Dialysis Modality In-center 43,25682.940,91878.4 Home HD 2600.52580.5 CAPD 1,4052.71,3022.5 CCPD 1,1742.21.3952.7 Uncertain a 528710.14470.9 Outcomes b Death 2010.45,34810.3 Transplant 5891.17011.3 Lost to follow-up 5<0.1 Recovered 1,7983.5 Total 52,17210052,172100

5. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data. Abbreviation: DaVita, DaVita Kidney Care; ESRD, end-stage renal disease; LDO, large dialysis organization; VA, Veterans' Affairs. Figure 8.2 Annualized monthly unadjusted mortality of incident ESRD veterans who transitioned to ESRD during 10/1/2007-9/30/2011 and who were followed for up to 36 months, by dialysis provider Vol 1, CKD, Ch 85

6. (Continued on next slide) Table 8.3 Annualized month-by-month unadjusted mortality in 52,172 incident ESRD veterans during the first 24 months after transition to ESRD by dialysis provider, 10/1/2007-9/30/2011 Vol 1, CKD, Ch 86 DVTFMCOther ChainsNon-ChainVHA MonthDiedAliveRate %DiedAliveRate %DiedAliveRate %DiedAliveRate %DiedAliveRate % 13551276333.384181437634.89202684735.43581100539.0486510020.24 25381240852.036151395852.87300664554.185431064761.2112501426.8 34491187045.394801334343.17246634546.523921010446.56110490226.93 43771142139.613881286336.2208609940.92318971239.29100479225.04 53081104433.473531247533.96180589136.67254939432.4583469221.23 63061073634.23151212231.18142571129.84250914032.8282460921.35 72441043028.072771180728.15126556927.15255889034.4271452718.82 82171018625.562401153024.98116544325.57213863529.661445616.43 9217996926.122191129023.28122532727.48218842231.0678439521.3 10206975225.352331107125.26118520527.2176820425.7461431716.96 11198954624.891961083821.7103508724.3162802824.2263425617.76 12181934823.232261064225.4896498423.11173786626.3964419318.32 13184916724.092091041624.08107488826.27167769326.0571412920.63 14175898323.381831020721.5199478124.85157752625.0351405815.08 15143880819.482051002424.5479468220.25130736921.1762400718.57

7. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data. Provider is based on the patient's provider on Day 1. Rates represent the 12-month annualized rate. Abbreviations: DVT, DaVita Kidney Care; ESRD, end-stage renal disease; FMC, Fresenius Medical Care; VHA, Veterans' Health Administration. Table 8.3 Annualized month-by-month unadjusted mortality in 52,172 incident ESRD veterans during the first 24 months after transition to ESRD by dialysis provider, 10/1/2007-9/30/2011 (Continued) Vol 1, CKD, Ch 87 DVTFMCOther ChainsNon-ChainVHA MonthDiedAliveRate %DiedAliveRate %DiedAliveRate %DiedAliveRate %DiedAliveRate % 16 157866521.74219981926.7683460321.64147723924.3754394516.43 17 150850821.16182960022.7588452023.36125709221.1550389115.42 18 167835823.98195941824.8574443220.04138696723.7742384113.12 19 143819120.95177922323.0377435821.2123682921.6146379914.53 20 131804819.53161904621.3683428123.27124670622.1945375314.39 21 146791722.13159888521.4779419822.58119658221.753370817.15 22 151777123.32157872621.5973411921.27119646322.137365512.15 23 121762019.06131856918.3570404620.76122634423.0845361814.93 24 137749921.92184843826.1782397624.75130622225.0751357317.13

8. Data source: VHA Administrative data, CMS Medicare Inpatient and Outpatient data. An individual's data includes the period from 60 months prior to transition (prelude) to 24 months following transition (vintage). Abbreviations: ESRD, end- stage renal disease; mo, month. Figure 8.3 Medications prescribed to 52,172 incident ESRD veterans who transitioned to ESRD from 10/1/2007-9/30/2011 Vol 1, CKD, Ch 88

9. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data. An individual's data includes the period from 60 months prior to transition (prelude) to 24 months following transition (vintage). Abbreviations: ESRD, end-stage renal disease; K, potassium; mo, month. Figure 8.4 Detail of the medications prescribed to 52,172 incident ESRD veterans who transitioned to ESRD during 10/1/2007-9/30/2011 Vol 1, CKD, Ch 89

10. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data. An individual's data includes the period from 60 months prior to transition (prelude) to 24 months following transition (vintage). Upper Venn diagram: three major hospitalization categories; Lower Venn diagram: focus of hospital events during transition to ESRD. Abbreviations: ESRD, end-stage renal disease. Figure 8.5 Hospitalization events in 46,625 incident ESRD veterans who transitioned to ESRD during 10/1/2007-9/30/2011 Vol 1, CKD, Ch 810

11. Figure 8.6 The top 20 causes of hospitalizations in 46,625 incident ESRD veterans who were hospitalized at least once during the period between 60 months prior to ESRD transition (prelude) and 24 months following ESRD transition (vintage) Vol 1, CKD, Ch 811 (a) 10 of the top 20 causes of hospitalizations

12. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data. Abbreviations: ASHD, astherosclerotic heart disease; CHF, congestive heart failure; CKD, chronic kidney disease; COPD, chronic obstructive pulmonary disease; CVD, acute cerebrovascular disease; GI Hem, gastrointestinal hemorrhage; MI, myocardial infarction; mo, month; Resp Fail, respiratory failure; Skin Inf, skin infection; surg, surgical. Figure 8.6 The top 20 causes of hospitalizations in 46,625 incident ESRD veterans who were hospitalized at least once during the period between 60 months prior to ESRD transition (prelude) and 24 months following ESRD transition (vintage) Vol 1, CKD, Ch 812 (b) 10 of the top 20 causes of hospitalizations

13. (Continued on next slide) Table 8.4 Ranking of the top 20 causes of hospitalization in 46,625 incident ESRD veterans who were hospitalized at least once during the period between 60 months prior to ESRD transition (prelude) and 24 months following ESRD transition (vintage) Vol 1, CKD, Ch 813 Hospitalization Event Overall (7 year cohort) -60 to -12 months of prelude Last 12 months of prelude During ESRD transition First 6 months of vintage +6 to +24 months of vintage Congestive heart failure111 342 Dialysis access (graft) complication 2910 11 Hypertension 373234 Acute renal failure 432 1 8 Septicemia 5188723 Diabetes 644566 Atherosclerotic heart disease 729121510 Pneumonia 857875 Acute myocardial infarction 9656138 Cardiac dysrhythmias 10812131011 Fluid disorder/fluid overload 111311 127 Rehabilitation 12 1514912 Surgical complications 13141915119 Chronic kidney disease 1464515

14. Data source: VHA Administrative data, USRDS ESRD Database, CMS Medicare Inpatient and Outpatient data. Abbreviation: ESRD, end-stage renal disease. Table 8.4 Ranking of the top 20 causes of hospitalization in 46,625 incident ESRD veterans who were hospitalized at least once during the period between 60 months prior to ESRD transition (prelude) and 24 months following ESRD transition (vintage) (Continued) Vol 1, CKD, Ch 814 Hospitalization Event Overall (7 year cohort) -60 to -12 months of prelude Last 12 months of prelude During ESRD transition First 6 months of vintage +6 to +24 months of vintage Gastrointestinal hemorrhage 1516 1714 Chest pain 161016 Respiratory failure 17149 13 Skin infection 181118 Chronic obstructive pulmonary disease 191517 Acute cerebrovascular disease 201719 Peripheral and visceral atherosclerosis 19 Anemia 13 Urinary tract infection 20 1820 Other circulatory disease 16 Intestinal infection 20 Aortic; peripheral, visceral artery aneurysm 19 Multiple myeloma 20

15. Figure 8.7 Selected comorbid conditions for calculation of the Charlson Comorbidity Index prior to transition to ESRD in 47,555 incident ESRD veterans Vol 1, CKD, Ch 815 (a) Common comorbidities among veterans prior to transition to ESRD

16. Data source: VHA Administrative data, USRDS ESRD Database. Abbreviations: CHF, congestive heart failure; compl, complications; COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; Dz, disease; ESRD, end-stage renal disease; MI, myocardial infarction; Mod, moderate; PVD, periphral vascular disease; PUD, peptic ulcer disease; Sev, Severe. Figure 8.7 Selected comorbid conditions for calculation of the Charlson Comorbidity Index prior to transition to ESRD in 47,555 incident ESRD veterans Vol 1, CKD, Ch 816 (b) Charlson Comorbidity Index Score

17. Data source: VHA Administrative data, USRDS ESRD Database. Abbreviations: ESRD, end-stage renal disease; g/dL, grams per deciliter. Figure 8.8 Trend in blood hemoglobin levels during the prelude (pre-ESRD) period, over 20 calendar quarters in 28,717 veterans who later transitioned to ESRD during 10/1/2007-9/31/2011 Vol 1, CKD, Ch 817

18. Data source: VHA Administrative data, USRDS ESRD Database. Abbreviations: ESRD, end-stage renal disease; g/dL, grams per deciliter. Figure 8.9 Trend in serum phosphorus level during the prelude (pre-ESRD) period, over 36 months in 11,896 veterans who later transitioned to ESRD during 10/1/2007-9/31/2011 Vol 1, CKD, Ch 818

19. (Continued on next slide) Figure 8.10 Trend in eGFR during the prelude (pre-ESRD) period, over 20 calendar quarters in 30,245 veterans who later transitioned to ESRD during 10/1/2007-9/31/2011 Vol 1, CKD, Ch 819 (a) Stratified by age

20. Data source: VHA Administrative data, USRDS ESRD Database. Abbreviations: eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease. Figure 8.10 Trend in eGFR during the prelude (pre-ESRD) period, over 20 calendar quarters in 30,245 veterans who later transitioned to ESRD during 10/1/2007-9/31/2011 Vol 1, CKD, Ch 820 (b) Stratified according to ESRD etiology

21. Data source: VHA Administrative data, USRDS ESRD Database. Abbreviations: ESRD, end-stage renal disease.. Figure 8.11 Trend in blood glucose level during the prelude (pre-ESRD) period, over 20 calendar quarters in 29,920 veterans who later transitioned to ESRD during 10/1/2007-9/31/2011 Vol 1, CKD, Ch 821

22. Data source: Kaiser Permanente Southern California Electronic Health Records. Also see Figure 8.12. Abbreviations: ESRD, end-stage renal disease; KP-SC, Kaiser Permanente Southern California. Table 8.5 Age distribution of 5,989 KP-SC patients who transitioned to ESRD, 1/1/2007-12/31/2011 Vol 1, CKD, Ch 822 Age groupFrequencyPercent (%) <20 230.38 20-24 480.8 25-29 671.12 30-34 1171.95 35-39 1672.79 40-44 2784.64 45-49 3696.16 50-54 5509.18 55-59 71211.89 60-64 76712.81 65-69 77012.86 70-74 74812.49 75-79 67311.24 80-84 4327.21 85-89 2223.71 90-94 410.68 95+ 50.08

23. Data source: Kaiser Permanente Southern California Electronic Health Records. Also see Figure 8.6. Abbreviations: ESRD, end-stage renal disease; KP-SC, Kaiser Permanente Southern California. Figure 8.12 Age distribution of 5,989 KP-SC patients who transitioned to ESRD, 1/1/2007-12/31/2011 Vol 1, CKD, Ch 823

24. Data source: Kaiser Permanente Southern California Electronic Health Records. Abbreviation: ESRD, end-stage renal disease. Figure 8.13 Annualized mortality rate of the 5,989 incident dialysis patients over the first 24 months after ESRD transition (vintage) Vol 1, CKD, Ch 824

25. Data source: Kaiser Permanente Southern California Electronic Health Records. Abbreviation: ESRD, end-stage renal disease; mg/dL, milligrams per deciliter. Figure 8.14 Gradual rise in serum creatinine level during the period prior to ESRD transition (prelude) of 20 calendar quarters, among 5,989 patients who would transition to dialysis Vol 1, CKD, Ch 825

26. Data source: Kaiser Permanente Southern California Electronic Health Records. Abbreviation: eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; mL/min, milliliters per minute. Figure 8.15 eGFR during the period prior to ESRD transition (prelude) of 20 calendar quarters, among 5,989 patients who would transition to dialysis Vol 1, CKD, Ch 826

27. Figure 8.16 Selected comorbid conditions for calculation of the Charlson Comorbidity Index prior to transition to ESRD in 5,858 KP-SC patients Vol 1, CKD, Ch 827 (a) Common comorbidities among veterans prior to transition to ESRD

28. Data source: Kaiser Permanente Southern California Electronic Health Records. Abbreviations: CHF, congestive heart failure; compl, complications; COPD, chronic obstructive pulmonary disease; CVD, cerebrovascular disease; Dz, disease; ESRD, end-stage renal disease; KP-SC, Kaiser Permanente Southern California; MI, myocardial infarction; Mod, moderate; PVD, periphral vascular disease; PUD, peptic ulcer disease; Sev, Severe. Figure 8.16 Selected comorbid conditions for calculation of the Charlson Comorbidity Index prior to transition to ESRD in 5,858 KP-SC patients Vol 1, CKD, Ch 828 (b) Charlson Comorbidity Index Score