Trends, underlying-cause structure, and penetration of end-stage kidney disease involvement in U.S. mortality, 1999-2023: a multiple-cause-of-death analysis.

Authors

Kaide Xia, Junwen Wang, Zefa Meng, Jingwen Yan

Published in

Frontiers in public health. Volume 14. Pages 1831145. Epub Jun 19, 2026.

Abstract

End-stage kidney disease (ESKD) is often listed as a contributing rather than underlying cause of death, potentially understating its burden in underlying-cause surveillance. Using U.S. multiple-cause-of-death data, we evaluated trends, underlying-cause pathways, ESKD "penetration" into cause-specific mortality, and drivers of change in ESKD-involved deaths.
Using CDC WONDER Multiple Cause of Death data (1999-2023), we identified ESKD-involved deaths among adults aged ≥25 years and calculated age-adjusted mortality rates (AAMR; 2000 U.S. standard). Joinpoint regression was performed using a log-linear model with a maximum of two joinpoints. Model selection was conducted using the Joinpoint Regression Program's default permutation-test procedure and grid-search settings. Average annual percent change (AAPC) and 95% CIs were estimated over the prespecified analysis intervals. For race-specific analyses, AAPCs were restricted to 1999-2020 bridged-race files; for urbanization analyses, AAPCs were restricted to 1999-2020. Underlying-cause composition was assessed using ICD-10 chapters and the NCHS 113 selected-cause list. ESKD penetration (P_g,t ) was estimated within each underlying-cause group, and a symmetric two-factor decomposition separated changes in ESKD-involved deaths into scale versus penetration components, comparing pre-COVID-19 and COVID-19-era periods.
ESKD-involved AAMR increased from 14.51 (95% CI 14.33-14.69) per 100,000 in 1999 to 18.74 (18.58-18.91) in 2023 (AAPC 1.33%, 0.61-2.10). Increases were faster in males than females (2.06% vs. 1.07) and in adults aged ≥65 vs. 25-64 years (1.81% vs. 0.73). In race-specific analyses restricted to the 1999-2020 bridged-race files, Black individuals had the highest absolute mortality, whereas White individuals showed a significant increase. The underlying-cause structure shifted, with genitourinary causes becoming more prominent. P_g,t varied widely by cause and increased for selected categories, indicating growing ESKD co-occurrence with specific fatal pathways. Decomposition showed heterogeneous scale versus penetration contributions across causes and period-specific differences.
ESKD involvement in U.S. mortality rose from 1999 to 2023 with marked subgroup inequities and shifts in underlying-cause pathways. Monitoring ESKD as a contributing cause, together with cause-structure and scale-penetration analyses, provides information beyond underlying-cause surveillance to support integrated prevention addressing CKD progression and its cardiometabolic and infectious complications.

PMID:
42404946
Bibliographic data and abstract were imported from PubMed on 06 Jul 2026.

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