To the Editor:
Chronic kidney disease is a growing public health burden in the United States, with more than 808,000 people living with end-stage kidney disease.1
Individuals with kidney failure experience a high symptom burden requiring intensive resource use and have complex medical needs, making end-of-life care challenging. The place of death among patients with kidney failure listed as a cause of death is an important yet understudied indicator of health care access, quality of end-of-life services, and potential disparities in care. National reports on causes of death from other conditions have shown an increasing proportion of home and hospice deaths across chronic illnesses.2 Whether these patterns extend to individuals with kidney failure remains unclear. To address this gap, we used national mortality data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research database to examine adults dying of kidney failure.
Mortality data were obtained from publicly accessible records from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research, a national database produced by the National Center for Health Statistics that compiles US death certificate data regardless of insurance status from all 50 states and the District of Columbia.3 We included all deaths in which kidney failure (chronic kidney disease, stage 5, International Classification of Diseases, Tenth Revision, N18.5) was listed as an underlying or contributing cause of death. The primary outcome was location of death, which was categorized into settings as defined within the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research as follows: inpatient medical facility, outpatient medical facility or emergency room, decedent’s home, or hospice/nursing facility, with the latter 2 categories being grouped into a single hospice/nursing facility as done previously.4 Results were stratified based on year, sex, urbanization status, and race and ethnicity. The study used deidentified and publicly available data and therefore was exempt from institutional board review oversight.
Between 1999 and 2023, yearly deaths attributed to kidney failure more than doubled from 25,837-51,889, with aggregate data shown in Table 1. The proportion of deaths occurring in inpatient medical facilities declined from 69% (N = 17,713) in 1999 to 48.5% (N = 25,191) in 2023. Conversely, deaths occurring at home increased from 10.5% (N = 2,717) to 23.3% (N = 12,115), whereas deaths in hospice or nursing facilities increased from 10.6% (N = 2,743) to 20.8% (N = 10,792) (Fig 1).
Table 1.
Aggregated Data for Adults for Places of Death by Decedent Characteristics for Mortality Attributed to Kidney Failure (1999-2023)
| Decedent Characteristics | Total, n (%) | Medical Facility Inpatient (%) | Medical Facility Outpatient or ER (%) | Decedent Home (%) | Hospice or Nursing Facility (%) |
|---|---|---|---|---|---|
| No. of deaths | 1,010,846 (100) | 538,628 (53.3) | 52,333 (5.2) | 178,080 (17.6) | 206,121 (20.4) |
| Age, y | |||||
| 20-34 | 11,020 (1.1) | 7,450 (67.6) | 1,091 (9.9) | 1,559 (14.1) | 568 (5.2) |
| 35-49 | 58,316 (5.8) | 38,914 (66.7) | 5,169 (8.9) | 7,815 (13.4) | 4,525 (7.8) |
| 50-64 | 215,090 (21.3) | 135,738 (63.1) | 14,963 (7) | 30,197 (14.0) | 27,930 (13) |
| 65+ | 725,332 (71.8) | 355,788 (49.1) | 31,001 (4.3) | 138,320 (19.1) | 173,072 (23.9) |
| 65-74 | 262,986 (26.0) | 152,187 (15.1) | 14,544 (1.4) | 41,403 (4.1) | 47,068 (4.7) |
| 75-84 | 290,045 (29.0) | 144,719 (14.3) | 12,098 (1.2) | 54,667 (5.4) | 67,995 (6.7) |
| 85+ | 172,301 (17.0) | 58,882 (5.8) | 4,359 (0.4) | 42,250 (4.2) | 58,009 (5.7) |
| Sex | |||||
| Female | 465,746 (46.1) | 245,795 (52.8) | 22,278 (4.8) | 78,919 (16.9) | 101,360 (21.8) |
| Male | 545,100 (53.9) | 292,833 (53.7) | 30,055 (10.3) | 99,161 (18.2) | 104,761 (19.2) |
| Race | |||||
| White | 691,266 (68.4) | 344,658 (50) | 255,309 (36.9) | 134,989 (19.5) | 156,329 (22.6) |
| Black | 267,386 (26.5) | 163,433 (61.1) | 18,933 (7.1) | 33,330 (12.5) | 42,972 (16.1) |
| American Indian | 11,220 (1.1) | 6,701 (59.7) | 682 (6.1) | 1,965 (17.5) | 1,490 (13.3) |
| Asian or Pacific Islander | 38,995 (3.9) | 22,834 (58.6) | 2,519 (6.5) | 7,308 (18.7) | 5,033 (12.9) |
| Hispanic origin | |||||
| Hispanic | 111,613 (11.0) | 66,665 (59.7) | 6,002 (5.4) | 21,189 (19.0) | 14,682 (13.2) |
| Non-Hispanic | 896,828 (88.7) | 470,573 (52.5) | 46,171 (5.1) | 156,616 (17.5) | 190,951 (21.3) |
| Not stated | 2,405 (0.2) | 1,390 (57.8) | 160 (6.7) | 275 (11.4) | 488 (20.3) |
| Urbanization | |||||
| Large metro | 549,431 (54.4) | 300,711 (54.7) | 29,554 (5.4) | 92,185 (16.9) | 107,810 (19.6) |
| Medium/small metro | 304,612 (30.1) | 155,138 (50.9) | 15,107 (5) | 56,929 (18.9) | 66,214 (21.7) |
| Rural | 156,803 (15.5) | 82,779 (52.8) | 7,672 (4.9) | 28,966 (18.5) | 38,557 (24.6) |
Figure 1.
Temporal trends in the place of death from mortality attributed to kidney failure among adults in the United States, 1999-2023.
All racial and ethnic groups showed the highest proportion of deaths in inpatient settings. Compared with others, White patients were the least likely to die in inpatient facilities (49.9%) and most likely to die in hospice or nursing settings (22.6%), whereas Black patients exhibited the highest proportion of inpatient deaths (61.1%) and were the least likely to die at home (12.5%) (Fig 2). Hispanic individuals were more likely to die in inpatient facilities (59.7% vs 52.5%) and less likely to die in hospice or nursing facilities (13.2% vs 21.3%) compared with non-Hispanic individuals (Table 1 and Fig 2).
Figure 2.
Place of death from mortality attributed to kidney failure among adults in the United States based on race/ethnicity, 1999-2023. Abbreviation: ER, emergency room.
In this analysis, we present the most current data on the place of death in the growing population in which cause of death was attributed to kidney failure. We observed a substantial shift in the place of death over the past 2 decades, with a decline in inpatient deaths and an increase in deaths occurring at home and in hospice and nursing facilities. We also noted important racial differences, with Black patients more likely to die in inpatient settings and less likely to die at home compared with White patients.
These findings are consistent with prior data, which reported an increase in the proportion of home, nursing facility, and hospice facility deaths among patients with kidney failure.5 Our findings expand on these prior analyses with a description of location of death among patients with kidney failure in the latest available mortality data and demonstrate continued trends of decline in inpatient deaths and increase in home deaths. Compared with prior studies on advanced kidney disease, our analyses evaluated a larger sample size by including deaths in which kidney failure was either the underlying or the contributing cause, which may provide a more comprehensive cohort of those dying from kidney failure.6 Importantly, we also observed persistent racial differences in the place of death, with Black patients more likely to die in inpatient medical facilities and less likely to die at home compared with White patients. These disparities are consistent with prior studies showing lower palliative care use in Black adults with kidney disease, suggesting that structural, socioeconomic factors and potential distrust in the health care system may influence end-of-life experiences in this population.5,7 Unique end-of-life decision barriers including lack of hospice eligibility for dialysis recipients and limited nephrology-palliative care integration may exacerbate these disparities.8 Importantly, because dialysis is a life-prolonging therapy rather than a curative one, inadequate communication around prognosis and treatment options may influence patient choices. In a prospective study of 584 patients with chronic kidney disease stages 4-5, 61% reported regret after initiating dialysis, and >90% reported that they had not engaged in an end-of-life care discussion with their nephrologist in the past 12 months.9 These findings highlight substantial gaps in patient understanding of the expected illness trajectory surrounding dialysis initiation and emphasize the urgency to integrate early, patient-centered, and culturally competent end-of-life communication within routine nephrology care to ensure that care aligns with patients’ end-of-life goals.
Our study has limitations. Cause of death determination may be subject to inaccuracies. In addition, the database does not capture advance directives, patient preference, or other important sociodemographic characteristics that may influence the place of death. Classification of location of death may not indicate hospice status at the time of death. In addition, the database does not capture dialysis status at the time of death. Despite these limitations, the use of a national, population-level mortality database provides a comprehensive review of the end-of-life care patterns among individuals dying of kidney failure.
In conclusion, among adults dying of kidney failure in the United States, the location of death is transitioning from inpatient medical settings toward home, hospice, and nursing facility settings. Although this trend aligns with broader end-of-life care shifts, racial and ethnic disparities persist, calling for the need for equitable access to end-of-life counseling and palliative and home-based services.
Article Information
Authors’ Contributions
Research area and study design: AS, DA; data acquisition: AS, DA; data analysis and interpretation: AS, NM, TY, ROM, SN, AA, DA; statistical analysis: AS, DA; supervision and mentorship: DA. Each author contributed important intellectual content during manuscript drafting or revision and accepts accountability for the overall work by ensuring the questions pertaining to the accuracy or integrity of any portion of the work are appropriately investigated or resolved.
Support
None.
Financial Disclosure
The authors declare that they have no relevant financial interests.
Peer Review
Received November 25, 2025. Evaluated by 2 external peer reviewers, with direct editorial input from an Associate Editor and the Editor-in-Chief. Accepted in revised form March 11, 2026.
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