{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T04:53:16Z","timestamp":1781844796652,"version":"3.54.5"},"reference-count":48,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T00:00:00Z","timestamp":1781827200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>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 \u201cpenetration\u201d into cause-specific mortality, and drivers of change in ESKD-involved deaths.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      Using CDC WONDER Multiple Cause of Death data (1999\u20132023), we identified ESKD-involved deaths among adults aged \u226525\u202fyears 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\u2019s 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\u20132020 bridged-race files; for urbanization analyses, AAPCs were restricted to 1999\u20132020. Underlying-cause composition was assessed using ICD-10 chapters and the NCHS 113 selected-cause list. ESKD penetration (\n                      <jats:italic>\n                        P\n                        <jats:sub>g,t<\/jats:sub>\n                      <\/jats:italic>\n                      ) 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\u2013COVID-19 and COVID-19-era periods.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      ESKD-involved AAMR increased from 14.51 (95% CI 14.33\u201314.69) per 100,000 in 1999 to 18.74 (18.58\u201318.91) in 2023 (AAPC 1.33%, 0.61\u20132.10). Increases were faster in males than females (2.06% vs. 1.07) and in adults aged \u226565 vs. 25\u201364\u202fyears (1.81% vs. 0.73). In race-specific analyses restricted to the 1999\u20132020 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.\n                      <jats:italic>\n                        P\n                        <jats:sub>g,t<\/jats:sub>\n                      <\/jats:italic>\n                      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.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>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\u2013penetration analyses, provides information beyond underlying-cause surveillance to support integrated prevention addressing CKD progression and its cardiometabolic and infectious complications.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1831145","type":"journal-article","created":{"date-parts":[[2026,6,19]],"date-time":"2026-06-19T04:29:52Z","timestamp":1781843392000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Trends, underlying-cause structure, and penetration of end-stage kidney disease involvement in U.S. mortality, 1999\u20132023: a multiple-cause-of-death analysis"],"prefix":"10.3389","volume":"14","author":[{"given":"Kaide","family":"Xia","sequence":"first","affiliation":[{"name":"Guiyang Children's Hospital, The Maternal and Child Health Care Hospital of Guizhou Medical University","place":["Guiyang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Junwen","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Psychosomatic Medicine, The Second People\u2019s Hospital of Guiyang","place":["Guiyang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zefa","family":"Meng","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Zhejiang Provincial People\u2019s Hospital Bijie Hospital (The First People\u2019s Hospital of Bijie)","place":["Bijie, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jingwen","family":"Yan","sequence":"additional","affiliation":[{"name":"Department of Nephrology, Zhejiang Provincial People\u2019s Hospital Bijie Hospital (The First People\u2019s Hospital of Bijie)","place":["Bijie, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,6,19]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","first-page":"A8","DOI":"10.1053\/j.ajkd.2025.02.602","article-title":"US kidney data system 2024 annual data report: epidemiology of kidney disease in the United States","volume":"85","author":"Johansen","year":"2025","journal-title":"Am J Kidney Dis"},{"key":"ref2","doi-asserted-by":"publisher","first-page":"190","DOI":"10.1016\/j.mpmed.2022.12.008","article-title":"Cardiovascular complications of chronic kidney disease","volume":"51","author":"Mayne","year":"2023","journal-title":"Medicine"},{"key":"ref3","doi-asserted-by":"publisher","first-page":"195","DOI":"10.1186\/s12933-023-01937-x","article-title":"The cardio-kidney-metabolic connection: a review of the evidence","volume":"22","author":"Marassi","year":"2023","journal-title":"Cardiovasc 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