ArticleFrontiers in public health2026
Trends, underlying-cause structure, and penetration of end-stage kidney disease involvement in U.S. mortality, 1999-2023: a multiple-cause-of-death analysis.
Article in Frontiers in public health, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: 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. Methods: 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 ( Results: 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. Conclusion: 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.
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