Puerto Rico carries one of the highest kidney disease burdens in the United States — a crisis compounded by the island’s uniquely high rates of diabetes, hypertension, and obesity. With an estimated 500,000 residents living with some stage of chronic kidney disease (CKD) out of a total population of 3.2 million, and an end-stage renal disease (ESRD) prevalence that surpasses the national average, Puerto Rico faces a public health emergency that is growing in severity with each passing year.
The burden of kidney disease in Puerto Rico is not only clinical but structural. A rapidly declining network of dialysis facilities — down more than 70% since 2019 — must serve a patient population that continues to grow. The island’s single kidney transplant center, unaffiliated with national donor-matching networks, performed just six living donor transplants in the past year for a waiting list of 297. Medicare spending on dialysis patients averages nearly three times the cost of transplant care, making the access gap both a humanitarian and a financial concern.
This article presents a comprehensive statistical portrait of kidney disease in Puerto Rico, covering disease prevalence, risk factors, ESRD incidence trends, recent burden changes, mortality, Medicare spending, dialysis patient characteristics, home dialysis utilization, kidney cancer statistics, and transplant access and outcomes.
Disease Burden and Prevalence
CKD and ESRD Prevalence
- Residents living with CKD (stages 1–5): ~500,000 out of 3.2 million
- ESRD prevalence (as of 2020): ~8,038 people
- ESRD prevalence vs. U.S. national average: higher
- Adults living with ESRD (2010): ~6,091 persons aged ≥18
- Adults who began ESRD treatment (2010): 1,462 persons
- Patients currently waiting for a kidney transplant: 297
The estimated 500,000 CKD patients represent approximately 15.6% of Puerto Rico’s total population. Even the more conservative official ESRD estimate of 8,038 (as of 2020) exceeds the national rate, placing Puerto Rico among the most affected populations in the United States.
Recent Trends (2019–2023)
More recent data shows Puerto Rico’s kidney disease burden worsening since 2019, while the infrastructure and workforce needed to address it have simultaneously contracted.
- Prevalence of CKD: increased by 9.3%
- Incidence of kidney failure: increased by 0.9%
- Prevalence of kidney failure: increased by 15.3%
- Number of hemodialysis facilities: decreased by 70.5%
- Total number of nephrologists: decreased by 9.6%
These figures reveal a dangerous and widening mismatch. Kidney failure prevalence is up 15.3% while hemodialysis facilities have been reduced by more than 70%, and the nephrologist workforce has contracted by nearly 10%.
Causes and Risk Factors
Key Risk Conditions
Multiple intersecting risk factors create an especially severe kidney disease burden in Puerto Rico.
| Condition | Puerto Rico Prevalence | Comparison |
| Diabetes | 17.6% | — |
| Hypertension | 42% | vs. 31% in the mainland U.S. |
| Overweight or obesity (BMI, self-reported) | 66% | — |
Leading Risk Factors for Poor Health and Early Death — Puerto Rico, 2021
- High blood sugar
- Obesity and overweight
- High blood pressure
- Kidney dysfunction
- Smoking
Puerto Rico’s hypertension rate is 35% higher than the mainland U.S. figure, and two-thirds of residents carry excess weight. Nearly 1 in 5 have diabetes — the primary driver of kidney failure on the island. Kidney dysfunction itself ranks 4th as a risk factor, indicating that impaired kidney function creates a feedback loop: it raises blood pressure and worsens metabolic disease, accelerating further decline.
Primary Causes of ESRD
The following data describes the leading causes of ESRD among Puerto Rico’s adult population and compares them with dialysis patient groups on the mainland.
New Adult Cases
- Diabetes: 66% of new adult ESRD cases
- Hypertension: 15% of new adult ESRD cases
Dialysis Initiation by Population Group (2013–2020)
| Cause | US White | US Hispanic | PR Hispanic |
| Diabetes | 44.2% | 59.7% | 67.1% |
| Hypertension | 24.8% | 20.7% | 16.7% |
| Other | 31.0% | 19.6% | 16.2% |
Diabetes drives kidney failure in Puerto Rico at a rate unmatched by either mainland comparison group — 67.1% of dialysis initiation among PR Hispanic patients versus 44.2% among US White patients. Hypertension, while highly prevalent on the island, accounts for a smaller share of ESRD initiation (16.7%) than in US White patients (24.8%), likely because it so often co-occurs with diabetes in Puerto Rican patients that diabetes becomes the primary attributed cause.
ESRD Incidence Trends Attributed to Diabetes (1996–2010)
A longitudinal dataset tracks ESRD specifically attributed to diabetes (ESRD-D) among Puerto Rico’s adult population. The number of new cases grew substantially over the period, with a sharp rise followed by a partial decline.
Annual Adults Initiating ESRD-D Treatment
- 1996: 536 persons
- 2010: 970 persons
Age-Adjusted ESRD-D Incidence Rates (per 100,000 population with diabetes), by Group and Trend Period
| Group | 1996 Rate | 2010 Rate | Period | APC (95% CI) | p-value |
| Total (Crude) | 193.5 | 267.9 | 1996–2000 | +11.5 (7.2–15.9) | <0.001 |
| Total (Crude) | 193.5 | 267.9 | 2000–2005 | −3.9 (−7.0–−0.7) | 0.02 |
| Total (Crude) | 193.5 | 267.9 | 2005–2010 | +1.9 (0.1–3.7) | 0.05 |
| Total (Age-adjusted) | 152.8 | 203.1 | 1996–2000 | +12.4 (3.3–22.4) | 0.01 |
| Total (Age-adjusted) | 152.8 | 203.1 | 2000–2010 | −2.3 (−4.1–−0.5) | 0.02 |
| Ages 18–44 | 96.4 | 132.0 | 1996–2002 | +13.1 (5.1–21.8) | 0.004 |
| Ages 18–44 | 96.4 | 132.0 | 2002–2010 | −6.3 (−10.5–−1.9) | 0.01 |
| Ages 45–64 | 205.9 | 261.9 | 1996–2010 | −0.4 (−1.8–1.0) | 0.55 (NS) |
| Ages 65–74 | 234.0 | 382.0 | 1996–2010 | +2.9 (1.4–4.4) | 0.001 |
| Ages ≥75 | 236.8 | 254.5 | 1996–2010 | −0.5 (−3.7–2.8) | 0.73 (NS) |
| Men (Age-adjusted) | 171.9 | 279.8 | 1996–2001 | +13.4 (6.9–20.3) | <0.001 |
| Men (Age-adjusted) | 171.9 | 279.8 | 2001–2010 | −3.1 (−5.7–−0.5) | 0.03 |
| Women (Age-adjusted) | 130.7 | 138.3 | 1996–2010 | −0.6 (−2.6–1.5) | 0.56 (NS) |
APC = Annual Percent Change. NS = Not statistically significant.
ESRD-D rates spiked sharply between 1996 and 2000–2001, rising over 12% per year on an age-adjusted basis, before declining significantly — suggesting improvements in diabetes management had a moderating effect. The partial rebound in crude rates between 2005 and 2010 signals that these gains were not fully sustained. The most concerning subgroup is adults aged 65–74, whose rates rose consistently at +2.9% per year throughout the full period, reaching 382.0 per 100,000 by 2010.
Kidney Cancer
Incidence and Prevalence
Kidney and renal pelvis cancer is a distinct condition from CKD and ESRD. The following data covers kidney cancer incidence, mortality, and prevalence in Puerto Rico.
- New Cases: 420 (rank 12th among all cancers; 2.5% of all cancers; cumulative risk 0.72)
- Deaths: 174 (rank 15th among cancer deaths; 2.2% of all cancer deaths; cumulative risk 0.28)
- 5-Year Prevalence: 1,381 cases (rate of 42.6 per 100,000)
Rates Compared to the United States (2018–2022)
The following tables compare kidney cancer incidence in Puerto Rico against national figures for the most recent available periods.
| Indicatior | Age-Adjusted Rate (per 100,000) | 95% CI | Avg. Annual Cases | % Late Stage |
| Puerto Rico — All Stages | 9.0 | (8.6–9.5) | 414 | 24.1% |
| United States — All Stages | 17.5 | (17.5–17.6) | 70,592 | 29.1% |
| Puerto Rico — Late Stage Only | 2.0 | (1.9–2.2) | 100 | — |
| United States — Late Stage Only | 5.0 | (5.0–5.0) | 20,556 | — |
United States and Puerto Rico Combined (1999–2022)
| Metric | Value |
| Count | 36,550 |
| Cumulative Population | 607,753,173 |
| Age-Adjusted Incidence Rate (per 100,000) | 6.5 |
| 95% Confidence Interval | (6.4–6.5) |
Puerto Rico’s kidney cancer incidence rate (9.0 per 100,000) is roughly half the corresponding U.S. figure (17.5).
Top 10 Cancer Sites Among Males — Puerto Rico (2015–2019, N = 38,750 total cases)
| Cancer Site | % of Male Cancers | APC 2000–2019 | Trend |
| Prostate | 38.3% | −0.1 | Stable |
| Colon and rectum | 11.7% | 0.0 | Stable |
| Lung and bronchus | 5.4% | −1.0* | Falling |
| Urinary bladder | 4.2% | 0.1 | Stable |
| Non-Hodgkin Lymphoma | 3.9% | +2.2* | Rising |
| Oral cavity and pharynx | 3.6% | −0.7* | Falling |
| Liver and bile duct | 3.4% | +1.7* | Rising |
| Kidney and renal pelvis | 3.1% | +4.2* | Rising |
| Leukemia | 2.8% | +2.1* | Rising |
| Pancreas | 2.4% | +3.4* | Rising |
* indicates statistically significant trend
Among males, kidney and renal pelvis cancer has the highest annual percent change of any cancer in the top 10 (+4.2% per year, 2000–2019) — rising faster than pancreatic (+3.4%), non-Hodgkin Lymphoma (+2.2%), and all others. If this trajectory is sustained, kidney cancer will move higher in male cancer rankings in the coming years.
Dialysis: Access, Characteristics, and Utilization
Medicare Spending by Treatment Type
The following data presents annual Medicare expenditures per person by treatment type for Puerto Rico’s ESRD population.
| Treatment Category | Patients | Patient Years at Risk | Medicare ($/Person/Year) |
| All ESRD | 3,293 | 2,900 | $51,104 |
| All Dialysis | 2,804 | 2,433 | $57,049 |
| Hemodialysis | 2,574 | 2,207 | $57,886 |
| Other Dialysis | 7 | 1 | $36,232 |
| Transplant | 553 | 467 | $20,117 |
Transplant recipients incur approximately 65% lower Medicare costs per year ($20,117) compared to dialysis patients ($57,049). With 2,804 patients on dialysis and only 553 on transplant status, the treatment mix is heavily weighted toward the more expensive modality.
Patient Characteristics and Comorbidities
Data from a study of 639,307 incident dialysis patients between 2013 and the third quarter of 2020 compares key patient and facility characteristics across US White, US Hispanic, and PR Hispanic populations.
| Characteristic | US White | US Hispanic | PR Hispanic |
| Number of patients | 491,400 (76.9%) | 137,381 (21.5%) | 10,526 (1.6%) |
| Mean age (years) | 66.23 | 59.22 | 64.03 |
| Female | 40.1% | 40.7% | 39.4% |
| Primary cause: Diabetes | 44.2% | 59.7% | 67.1% |
| Primary cause: Hypertension | 24.8% | 20.7% | 16.7% |
| Primary cause: Other | 31.0% | 19.6% | 16.2% |
| Congestive heart failure | 30.9% | 21.8% | 37.7% |
| Ischemic heart disease | 16.5% | 9.4% | 39.9% |
| Myocardial infarction | 24.3% | 13.7% | 13.1% |
| Hypertension (comorbidity) | 86.1% | 88.7% | 94.1% |
| Diabetes with retinopathy | 5.5% | 9.2% | 34.1% |
| Hemoglobin level (g/dL) | 9.49 | 9.22 | 9.54 |
| Serum albumin level (g/dL) | 3.23 | 3.15 | 3.13 |
| Body mass index | 29.92 | 28.99 | 28.55 |
| Predialysis nephrology care received | 79.5% | 69.2% | 63.3% |
| Insurance: Dual | 10.3% | 18.0% | 4.4% |
| Insurance: Medicare | 61.2% | 29.1% | 61.1% |
| Insurance: Medicaid | 8.3% | 23.8% | 11.0% |
| Insurance: Other | 20.2% | 29.1% | 23.4% |
| Facility: For-profit | 87.5% | 89.7% | 99.3% |
| Facility: Chain-owned | 88.3% | 85.8% | 98.6% |
| Facility offers home hemodialysis training | 37.6% | 23.0% | 16.6% |
| Facility offers peritoneal dialysis | 62.3% | 54.8% | 70.3% |
Puerto Rico’s dialysis patients present a distinctly more complex clinical profile. Ischemic heart disease affects 39.9% of PR Hispanic patients — more than double the US White rate (16.5%) and more than four times the US Hispanic rate (9.4%). Diabetes with retinopathy, a marker of advanced systemic diabetic disease, is present in 34.1% of PR patients compared to 5.5% of US White patients — a more than sixfold difference, indicating that many patients arrive at dialysis already experiencing severe systemic complications.
Home Dialysis Utilization
Home dialysis offers greater patient flexibility and comparable or improved outcomes relative to in-center hemodialysis. The data below compares utilization rates from 2013 to 2020 across population groups.
| Population | 2013 Rate (95% CI) | 2020 Rate (95% CI) | Change |
| US White | 10.61% (10.36–10.87%) | 15.70% (15.38–16.01%) | +5.09 pp |
| US Hispanic | 8.48% (7.99–8.98%) | 12.75% (12.21–13.29%) | +4.27 pp |
| PR Hispanic | 5.83% (4.11–7.56%) | 6.01% (3.86–8.16%) | +0.18 pp (stable) |
pp = percentage points
Adjusted Differences in Home Dialysis Rates (2020, relative to PR Hispanic patients):
- PR Hispanic vs. US White: −7.12 percentage points (95% CI: −9.13 to −5.11)
- PR Hispanic vs. US Hispanic: −6.28 percentage points (95% CI: −8.33 to −4.23)
Note: After adjusting for patient and facility characteristics, differences between US White and US Hispanic patients decreased substantially or were no longer statistically significant. PR patients remained significantly below both mainland groups throughout the study period, and differences persisted even after stratifying by patients who received care at facilities offering home hemodialysis training.
While home dialysis use rose dramatically on the mainland — by more than 5 percentage points for US White patients between 2013 and 2020 — Puerto Rico’s rate remained essentially flat at under 6%. The persistence of this gap even after statistical adjustment for patient demographics and facility characteristics points to structural, economic, or awareness barriers specific to Puerto Rico that go beyond facility availability alone.
Kidney Transplant
Puerto Rico has a single kidney transplant center: Auxilio Mutuo Hospital. Recipient outcome data covers the period April 1, 2025 through March 31, 2026.
Transplant Center Program Features
Transplant Activity
- NKR Transplants (Last 12 Months): 0
- Living Donor Transplants (Prior Year): 6
- NKR Living Donor Transplants (Prior Year): 0
- NKR % of Living Donor Transplants: 0%
- Low Eplet Transplants (Last 12 Months): 0
Program Enrollment
- NKR Member Center: No
- Equal Access Commitment: No
- Voucher Program: No
- Kidney for Life: No
- Patient Microsites: No
- Microsite Center of Excellence: No
- Non-Steroidal Protocol: Unknown
Donor Programs
- Prioritization — Deceased Donor: No
- Prioritization — Living Donor: No
- Donor Shield: No
- NKR Remote Donation: No
- Donor Referral Network: No
- Donor Care Network: No
- Nutcracker Care Network: No
Transplant Outcomes
Adult Outcomes
| Outcome Metric | Living Donor | Deceased Donor |
| 1-Year Graft Survival | 100% | 94% |
| 3-Year Graft Survival | 100% | 93% |
| 1-Year Patient Survival | 100% | 96% |
| 3-Year Patient Survival | 100% | 93% |
Pediatric Outcomes
| Outcome Metric | Living Donor | Deceased Donor |
| 1-Year Graft Survival | 100% | 80% |
| 3-Year Graft Survival | 100% | 91% |
| 1-Year Patient Survival | 100% | 100% |
| 3-Year Patient Survival | 100% | 91% |
Note: Centers with higher transplant volumes are less likely to achieve 100% survival rates in any given category. Centers that accept more medically complex cases may also have lower survival rates. All outcome data is based on 6 living donor transplants in the prior year.
With 297 patients on the transplant waiting list, only 6 living donor transplants performed in the prior year, and zero NKR-facilitated transplants, Puerto Rico’s transplant access is critically inadequate relative to need. The sole transplant center is not a member of the National Kidney Registry and participates in none of the advanced donor-matching programs listed — programs that could substantially expand access to compatible kidneys for Puerto Rican patients.
Mortality and Public Health Impact
Kidney Disease Death Rates
The following data compares kidney disease (nephritis and nephrosis) mortality in Puerto Rico against the national average for the period 2019–2023.
| Metric | Puerto Rico | United States |
| Age-Adjusted Death Rate (per 100,000) | 18.9 (95% CI: 18.4–19.5) | 13.4 (95% CI: 13.3–13.4) |
| Average Annual Deaths | 1,045 | 54,332 |
| Recent 5-Year Trend | Rising | Stable |
| 5-Year Trend Rate, APC (95% CI) | +8.0% (2.8–13.5) | 0.0% (−0.3–0.5) |
Puerto Rico’s kidney disease death rate (18.9 per 100,000) is 41% above the national figure (13.4), and is rising at 8.0% per year while the U.S. trend is stable. This gap is actively widening.
Kidney & Renal Pelvis Cancer Death Rates (2019–2023)
- Puerto Rico: 1.7 per 100,000 (95% CI: 1.6–1.9); 93 average annual deaths; trend: stable
- United States: 3.4 per 100,000 (95% CI: 3.4–3.5); 14,378 average annual deaths; trend: falling
While U.S. kidney cancer mortality is falling, Puerto Rico’s trend is stable — the island is not keeping pace with national improvements.
Kidney Disease in National Rankings
Kidney disease features prominently among Puerto Rico’s leading causes of death and causes of poor health, reflecting the condition’s outsized impact on both mortality and quality of life.
Leading Causes of Death (2020–2023)
- Heart disease — 18.3%
- Cancer — 15.7%
- Alzheimer disease — 9.0%
- Diabetes — 9.0%
- Unintentional injuries — 5.0%
- Kidney disease — 3.7%
- Stroke — 3.5%
- Chronic lower respiratory diseases — 3.1%
- Influenza and pneumonia — 2.8%
- COVID-19 — 2.3%
Leading Causes of Poor Health and Early Death (2021)
| Rank | Cause |
| 1 | Diabetes |
| 2 | Ischemic heart disease |
| 3 | Chronic kidney disease |
| 4 | COVID-19 |
| 5 | Interpersonal violence |
| 6 | Low back pain |
| 7 | Alzheimer’s disease and other dementias |
| 8 | Stroke |
| 9 | COPD |
| 10 | Age-related and other hearing loss |
Kidney disease ranks 6th as a cause of death but rises to 3rd as a cause of poor health and early death — a discrepancy that reflects the substantial disability and reduced quality of life that CKD and ESRD impose long before death.
Conclusion
The data presented across this article tells a consistent and alarming story. Puerto Rico’s kidney disease death rate is 41% above the national average and rising at 8% per year while the U.S. trend is stable. Kidney failure prevalence has grown 15.3% since 2019, CKD prevalence has grown 9.3%, and — among males — kidney and renal pelvis cancer is rising faster (+4.2% per year) than any other cancer in the top 10. Underlying all of these trends are some of the highest diabetes, hypertension, and obesity rates in the United States: three conditions that together account for over 80% of new ESRD cases on the island.
What makes this crisis especially acute is the simultaneous collapse of the infrastructure needed to address it. Hemodialysis facilities have decreased by 70.5% since 2019 even as kidney failure prevalence has grown, the nephrology workforce has shrunk by 9.6%, and home dialysis utilization — which has risen sharply on the mainland — has remained essentially flat in Puerto Rico at under 6%. The island’s sole transplant center performed zero NKR-facilitated transplants in the past year, participates in no national donor-matching programs, and serves a waiting list of 297 patients with just six living donor transplants annually. The result is that the overwhelming majority of Puerto Rico’s ESRD patients remain on dialysis indefinitely, at a Medicare cost nearly three times higher than transplant care.
Reversing this trajectory will require simultaneous action across multiple domains: earlier and more aggressive management of diabetes, hypertension, and obesity; rebuilding dialysis infrastructure and expanding the nephrology workforce; increasing home dialysis utilization through facility training programs and patient education; and urgently expanding transplant capacity, including affiliation with national kidney matching networks that could dramatically increase access to compatible donors. The statistical picture presented here makes the scale of the challenge clear — and the cost of inaction higher with every passing year.
Sources:
- Kidney Transplant Centers in Puerto Rico
- PUERTO RICO
- Leading causes of death in Puerto Rico by year, sex, and rank: 2020-2023
- Trends in Incidence of End-Stage Renal Disease Among Persons With Diagnosed Diabetes — Puerto Rico, 1996–2010 – PMC
- Puerto Rico Kidney Care Metrics
- The State of Health in Puerto Rico
- Home Dialysis Utilization in Puerto Rico – American Journal of Kidney Diseases
- Mortality Table for US by State | HDPulse Data Portal
- Incidence Rate Report for Puerto Rico Kidney & Renal Pelvis (Late Stage), 2018-2022
- State Cancer Profiles > Interpretation of Incidence Rates Data
- PUERTO RICO Kidney Cancer — Incidence, Mortality and Prevalence
- United States and Puerto Rico Cancer Statistics, 1999-2022 Incidence Results
- Death Rate Report for Puerto Rico Kidney & Renal Pelvis, 2019-2023
- Cancer Epidemiology in Puerto Rico 2015 2019