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Online Letters: Comments and Responses

Incidence of Treatment for End-Stage Renal Disease Among Individuals With Diabetes in the U.S. Continues to Decline

Response to Burrows, Li, and Geiss

  1. Emmanuel Villar, MD, PHD1,
  2. Stephen Peter McDonald, MBBS, FRACP, PHD2,3 and
  3. Cécile Couchoud, MD4
  1. 1Department of Nephrology, Hospices Civils de Lyon, Centre Hospitalier Lyon Sud, Pierre Bénite, France;
  2. 2Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, Woodville, South Australia, Australia;
  3. 3Department of Nephrology, The Queen Elizabeth Hospital, Woodville, South Australia, Australia;
  4. 4Renal Epidemiology and Information Network (REIN) Registry, Agence de la biomédecine, Saint Denis La Plaine, France.
  1. Corresponding author: Emmanuel Villar, emmanuel.villar{at}chu-lyon.fr.
Diabetes Care 2010 May; 33(5): e69-e69. https://doi.org/10.2337/dc10-0074
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We read with great interest the report from the U.S. Renal Data System (USRDS) by Burrows et al. (1) that described declining incidence rate of treated end-stage renal disease (ESRD) “related to diabetes” as primary renal disease among estimated U.S. population with diabetes. From 1996 to 2006 the overall incidence rate decreased at an average of 2.9% per year (1).

However, reported results raise the issue of the clinical relevance of this primary renal disease definition when a diabetic population is studied.

In ESRD patients, diabetes might be the cause of chronic kidney disease (diabetic nephropathy) or an associated disease not related to primary renal disease (diabetes as comorbidity). In type 2 diabetic patients with proteinuria, one-third had histological involvement unrelated to diabetic nephropathy, and multiple pathologies are also possible (2). In particular, diabetic nephropathy and hypertensive changes are likely to coexist (2). When based on the nephrologist's assessment of patients, as in the USRDS study (1), diabetes was reported as primary renal disease in only 52.6% of incident ESRD patients with associated type 2 diabetes in the French Renal Epidemiology and Information Network (REIN) registry in 2006 (3) and in 74.1% of such patients in the Australia and New Zealand Dialysis and Transplant (ANZDATA) registry from 1991 to 2005 (4). In these countries, renal biopsy was performed in <17% of incident ESRD patients with type 2 diabetes (3,4).

Extrapolation of the U.S. data reported by Burrows et al. raises several possibilities (1). Firstly, the definition ESRD “related to diabetes” may underestimate the total number of cases of ESRD among diabetic patients, as a proportion is likely to be reported as nondiabetic histology. Secondly, decline in disease-specific incidence of diabetes-related ESRD among diabetic patients might reflect changing diagnostic attribution rather than a true change in the rate of progression to diabetic nephropathy.

The authors assert that most diabetes-related ESRD incidence among people aged <45 years is likely to be due to type 1 diabetes. In the REIN registry, among ESRD patients aged <45 years with associated diabetes, only 58.0% had type 1 diabetes in 2006 (3). In the ANZDATA registry, the rate of type 1 diabetes decreased from 63.2% in 1991 to 48.4% in 2005 among ESRD patients aged <45 years with associated diabetes (4). Using 45 years as the cutoff age to discriminate between type 1 and type 2 diabetes may lead to misinterpretation, especially if nephropathy was used to discriminate diabetic and nondiabetic patients, because incidence of type 2 diabetes were increasing over time in younger patients as in elderly patients.

At least, differences in patient characteristics by diabetes types and relative changes in incidence and prevalence of diabetes in general population and in incidence of ESRD with associated diabetes are not likely to vary in the same manner between type 1 and type 2 diabetic patients over time.

For these reasons, we think it is important that epidemiology studies in ESRD populations include consideration of diabetes both as a cause of renal disease and as an associated condition or comorbidity and that type 1 and type 2 diabetic patients should be discriminated given their different etiology, management options, and prognosis (3,4,5).

Acknowledgments

No potential conflicts of interest relevant to this article were reported.

  • © 2010 by the American Diabetes Association.

Readers may use this article as long as the work is properly cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/licenses/by-nc-nd/3.0/ for details.

References

  1. ↵
    1. Burrows NR,
    2. Li Y,
    3. Geiss LS
    : Incidence of treatment for end-stage renal disease among individuals with diabetes in the U.S. continues to decline. Diabetes Care 2010; 33: 73– 77
    OpenUrlAbstract/FREE Full Text
  2. ↵
    1. Fioretto P,
    2. Caramori ML,
    3. Mauer M
    : The kidney in diabetes: dynamic pathways of injury and repair. The Camillo Golgi Lecture 2007. Diabetologia 2008; 51: 1347– 1355
    OpenUrl
  3. ↵
    1. Couchoud C,
    2. Villar E,
    3. Frimat L,
    4. Fagot-Campagna A,
    5. Stengel B
    : End-stage renal disease and diabetes: frequency and initial condition of replacement therapy, France, 2006. BEH 2008; 43: 414– 418
    OpenUrl
  4. ↵
    1. Villar E,
    2. Chang SH,
    3. McDonald SP
    : Incidences, treatments, outcomes, and sex effect on survival in patients with end-stage renal disease by diabetes status in Australia and New Zealand (1991–2005). Diabetes Care 2007; 30: 3070– 3076
    OpenUrlAbstract/FREE Full Text
  5. ↵
    1. Villar E,
    2. Polkinghorne KR,
    3. Chang SH,
    4. Chadban SJ,
    5. McDonald SP
    : Effect of type 2 diabetes on mortality risk associated with end-stage kidney disease. Diabetologia 2009; 52: 2536– 2541
    OpenUrlCrossRefPubMed
View Abstract
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Incidence of Treatment for End-Stage Renal Disease Among Individuals With Diabetes in the U.S. Continues to Decline
Emmanuel Villar, Stephen Peter McDonald, Cécile Couchoud
Diabetes Care May 2010, 33 (5) e69; DOI: 10.2337/dc10-0074

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Incidence of Treatment for End-Stage Renal Disease Among Individuals With Diabetes in the U.S. Continues to Decline
Emmanuel Villar, Stephen Peter McDonald, Cécile Couchoud
Diabetes Care May 2010, 33 (5) e69; DOI: 10.2337/dc10-0074
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