Incidence of Treatment for End-Stage Renal Disease Attributed to Diabetes Mellitus -- United States, 1980-1989

End-stage renal disease (ESRD) is defined as renal insufficiency requiring dialysis or kidney transplantation for survival. In the United States, diabetes mellitus is the major cause of ESRD (1). This report summarizes trends during the 1980s in the incidence of treatment for ESRD attributable to diabetes mellitus (ESRD-DM). *

Because 90% of ESRD treatment in the United States is reimbursed by Medicare's ESRD program, Medicare's medical information system has been used for surveillance of ESRD-DM (2,3). Incidence is defined as the initiation of treatment for ESRD-DM. ** Estimates of the number of persons with diabetes were derived from CDC's National Health Interview Survey (NHIS) and were used in the calculation of rates (3). Because of limitations in the sample size of the NHIS, race-specific analysis in this report is presented only for blacks and whites. Rates were age-adjusted by the direct method (4) using the estimated 1980 population of persons with diabetes as the standard.

From 1980 through 1989, new cases of ESRD-DM increased from 2220 to 13,332. Similarly, the age-adjusted incidence of ESRD-DM increased more than fivefold, from 38.4 to 202.0 per 100,000 persons with diabetes. Although the incidence varied inversely with age, age differences narrowed during the decade because incidence increased at a greater rate among the older age groups (Figure 1). Incidence among persons with diabetes increased threefold among those aged less than 45 years but increased 12-fold among those aged greater than or equal to 75 years.

The age-adjusted incidence of ESRD-DM was greater for blacks with diabetes than for whites with diabetes and highest for black females with diabetes (Figure 2). In 1989, the age-adjusted ESRD-DM incidence for black males was 1.4 times that for white males (284.6 versus 201.3 per 100,000 persons with diabetes), and the ESRD-DM incidence for black females was 2.3 times that for white females (352.8 versus 150.8 per 100,000 persons with diabetes). Among whites with diabetes, the incidence was greater in males than females. Among blacks with diabetes, during 1985-1986, the incidence in black females began to exceed that in black males. The rate of increase in ESRD-DM incidence was similar for blacks and whites but was higher for females than for males (approximately fivefold versus fourfold increase).

Reported by: Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The dramatic increase in occurrence of ESRD-DM during the 1980s may have reflected increases both in the incidence and in the treatment of this problem. Use of treatment may be influenced not only by availability but also by changes in the definition of eligibility for treatment (3). In addition, because Medicare does not reimburse approximately 10% of ESRD treatment and does not include as incident cases those persons who are neither candidates for treatment nor who choose not to be treated (3), the number of cases may be underreported.

Age-specific differences in incidence of ESRD-DM decreased during the decade because of greater increases in rates among older age groups. Because ESRD cases attributed to noninsulin-dependent diabetes mellitus (NIDDM) are more frequent in older age groups, the increased incidence in these age groups suggests that ESRD-DM associated with NIDDM is increasing (5).

The findings in this report indicate that the incidence of ESRD-DM was higher among blacks than whites. Rates for the incidence of ESRD and ESRD-DM among other minority groups are also higher than for whites (6). Factors accounting for these differences may include greater severity of diabetes, higher prevalence of hypertension, higher prevalence of uncontrolled diabetes and hypertension, and lack of access to preventive care and treatment (3,6,7).

Three levels of prevention efforts may help reduce the incidence of ESRD-DM. The first is the primary prevention of NIDDM (5), which accounts for 90%-95% of all incident cases of diabetes. Effective interventions using dietary and physical activity strategies are needed for persons in minority groups and others who may be at high risk for the development of NIDDM (5). The second level is the prevention of diabetic nephropathy, which is the precursor to ESRD-DM. Although strategies for preventing diabetic nephropathy are not well established (8,9), the efficacy of controlling hyperglycemia as a means for preventing diabetic nephropathy is being assessed by the National Institute of Diabetes and Digestive and Kidney Diseases in its Diabetes Control and Complications Trial (10). The third level of prevention efforts is to slow the progression of diabetic nephropathy to ESRD-DM. These efforts should focus on detecting early markers of renal disease and offering at-risk persons intensive interventions, which include

1. controlling hypertension, 2) limiting protein intake, 3) controlling hyperglycemia, 4) promptly treating urinary tract infections, and 5) identifying and eliminating barriers to preventive care and treatment (e.g., financial, geographic, and cultural barriers) (6-9).

References

1. US Renal Data System. USRDS 1989 annual data report. Bethesda, Maryland: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 1989.

2. Eggers PW, Connerton R, McMullan M. The Medicare experience with end-stage renal disease: trends in incidence, prevalence, and survival. Health Care Financing Review 1984;5:69-88.

3. CDC. Diabetes surveillance, 1991. Atlanta: US Department of Health and Human Services, Public Health Service, 1992.

4. Fleiss JL. Statistical methods for rates and proportions. 2nd ed. New York: John Wiley, 1981.

5. CDC. End-stage renal disease associated with diabetes -- United States, 1988. MMWR 1989;38:546-8.

6. Feldman HI, Klag MJ, Chiapella AP, Whelton PK. End-stage renal disease in US minority groups. Am J Kidney Dis 1992;19:397-410.

7. Rostand SG. US minority groups and end-stage renal disease: a disproportionate share [Editorial]. Am J Kidney Dis 1992;19:411-3.

8. CDC. The prevention and treatment of complications of diabetes: a guide for primary care practitioners. Atlanta: US Department of Health and Human Services, Public Health Service, 1991.

9. Herman W, Hawthorne V, Hamman R, et al. Consensus statement: preventing the kidney disease of diabetes mellitus -- public health perspectives. Am J Kidney Dis 1989;13:2-6.

10. Fitzsimmons SC, Agodoa L, Striker L, Conti F, Striker G. Kidney disease of diabetes mellitus: NIDDK initiatives for the comprehensive study of its natural history, pathogenesis, and prevention. Am J Kidney Dis 1989;13:7-10.

• These data are part of an ongoing national diabetes surveillance system that provides estimates of the prevalence and incidence of diaetes and its complications. A copy of the most recent surveillance report is available from the Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC, Mailstop K-10, 4770 Buford Highway, NE, Atlanta, GA 30341-3724. + Incidence data were provided by the Bureau of Data Management and Strategy, Health Care Financing Administration, from Medicare's ESRD program management and medical information system.

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