Incidence of Treatment for End-Stage Renal Disease Attributed to Diabetes Mellitus, by Race/Ethnicity -- Colorado, 1982-1989

Diabetes mellitus (DM) is the principal known cause of end-stage renal disease (ESRD) (i.e., renal insufficiency requiring kidney dialysis or transplantation for survival) and accounts for one third of all incident cases of treated ESRD in the United States (1). Rates for initiating diabetes-related ESRD (ESRD-DM) treatment have been characterized for blacks and whites but have not been well characterized for Hispanics (2-5). To describe ESRD-DM treatment by race/ethnicity in Colorado for improved program planning for intervention services, the Colorado Diabetes Surveillance Project of the Colorado Department of Health investigated differences in the rates of initiating ESRD-DM treatment for non-Hispanic white, Hispanic, and black Colorado residents with diabetes. This report describes trends in the incidence of ESRD-DM treatment by race/ethnicity among persons with diabetes in Colorado from 1982 through 1989.

Data regarding the treatment of persons with diabetes-related ESRD were obtained from the Intermountain End-Stage Renal Disease Network (ImESRDN).* ImESRDN collects demographic, etiologic, and other information for all patients undergoing renal replacement therapy (i.e., dialysis or kidney transplantation), regardless of their payment source, in Colorado and five other states in the Rocky Mountain region. Incident cases were defined as Colorado residents with diabetes who had a primary diagnosis of diabetic nephropathy and for whom renal replacement therapy was initiated during 1982-1989. The number of persons with diabetes in the state was estimated by applying national age-, sex-, and race/ethnicity-specific diabetes prevalence rates to Colorado population estimates for 1982-1989 (6). ESRD-DM treatment rates were age-adjusted using the estimated 1980 U.S. population with diabetes divided into four age groups: 0-44 years, 45-64 years, 65- 74 years, and greater than or equal to 75 years (7).

From 1982 through 1989, 874 Colorado residents began ESRD-DM treatment; of these, 562 (64%) were non-Hispanic white; 191 (22%), Hispanic; 80 (9%), black; and 41 (5%), persons of other races. In comparison, 78% of the estimated Colorado population with diabetes were non-Hispanic white, 17% were Hispanic, 4% were black, and 1% were persons of other races (6).

From 1982 through 1989, the age-adjusted incidence rate for ESRD-DM treatment more than tripled, increasing from 61 to 216 per 100,000 persons with diabetes (Figure 1). The greatest increase in rates was for Hispanics (770%), compared with blacks (440%) and non-Hispanic whites (190%). For persons with diabetes, the 8-year average annual age-adjusted rates for blacks and Hispanics were 2.8 and 1.8 times, respectively, that for non-Hispanic whites. For Hispanics and blacks, the overall age-adjusted incidence of treated ESRD-DM was greater for females than for males; for non-Hispanic whites, however, the overall incidence was higher for males than females. For non-Hispanic whites, the 8-year average annual rate for treated ESRD-DM was highest in the 0-44 age group (263 per 100,000 persons with diabetes) and decreased with age (Figure 2). However, for Hispanics, rates increased with age and were highest for persons aged greater than or equal to 75 years (293 per 100,000 persons with diabetes). For blacks, the highest age-specific incidence rate of ESRD-DM was for persons aged 45-64 years (483 per 100,000 persons with diabetes).

Reported by: RF Hamman, MD, Dept of Preventive Medicine and Biometrics, Univ of Colorado Health Sciences Center; A Turak, SK Stiles, MS, Intermountain End-Stage Renal Disease Network #15, Denver; FF Finucane, MHS, SL Michael, MS, CJ Garrett, PhD, C Meng, PhD, BA Gabella, Colorado Dept of Health. Epidemiology and Statistics Br, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that rates of initiation of treatment for ESRD-DM in Colorado are consistent with national patterns for blacks and whites (7). In many cases, this variability is likely related to environmental factors rather than genetic differences (8). However, data regarding ESRD treatment among Hispanics are limited.

In Colorado, Hispanics (primarily of Mexican and American Indian descent) are 13% of the total population and comprise the largest minority group. A previous report indicated that in Texas the incidence rate for ESRD-DM treatment for U.S. residents of Mexican descent was six times greater and the rate for blacks was four times greater than that for non-Hispanic whites in the general population (5). However, in Colorado, overall incidence rates of treated ESRD-DM for Hispanics were intermediate to those for blacks and non-Hispanic whites among persons with diabetes; this pattern persisted when total population rates were calculated (age-adjusted incidence rate ratios of 4.6 and 3.7 for blacks and Hispanics, respectively, when compared with non-Hispanic whites) (6). Potential explanations for these race/ethnicity differences may include variations in ESRD biologic risk factors, variations in the availability of ESRD treatment or in access to preventive care and ESRD services, changes in ESRD reporting practices, or a combination of these or other factors.

Two national health objectives for the year 2000 are to reduce the rate of initiating ESRD-DM treatment from 1.5 to 1.4 per 1000 persons with diabetes and from 2.2 to 2.0 per 1000 blacks with diabetes (objectives 17.10 and 17.10a) (9). Surveillance data indicate, however, that during the 1980s the rates for persons with diabetes increased annually in Colorado and throughout the United States (7).

The development of public health strategies to delay and prevent the development of ESRD-DM (10) will require the continued monitoring of trends in initiation of ESRD treatment. The ImESRDN is one potential monitoring system for assessing the effectiveness of proposed prevention strategies. These data may be useful in tracking national health objectives related to ESRD-DM and in developing prevention strategies for ESRD-DM, particularly among minority populations. Colorado has used these findings to develop a Diabetes State Plan for the Year 2000 and will use these data to monitor trends and direct interventions associated with diabetes-related ESRD treatment.

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

3. Stephens GW, Gillaspy J, Clyne D, Mejia A, Pollak VE. Racial differences in the incidence of end-stage renal disease in types I and II diabetes mellitus. Am J Kidney Dis 1990;15:562-7.

4. Cowie CC, Port FK, Wolfe RA, Savage PJ, Moll PP, Hawthorne VM. Disparities in incidence of diabetic end-stage renal disease according to race and type of diabetes. N Engl J Med 1989;321:1074-

6. Pugh JA, Stern MP, Haffner SM, Eifler CW, Zapata M. Excess incidence of treatment of end-stage renal disease in Mexican Americans. Am J Epidemiol 1988;127:135-44.

7. Health Statistics Section/Chronic Disease Section, Colorado Department of Health. Diabetes prevalence and morbidity in Colorado residents, 1980-1991. Denver: Colorado Department of Health (in press).

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

9. Cooper R. A note on the biologic concept of race and its application in epidemiologic research. Am Heart J 1984;108:715-23.

10. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

11. CDC. Incidence of treatment for end-stage renal disease attributed to diabetes mellitus -- United States, 1980-1989. MMWR 1992;41:834-7.

• ImESRDN is one of 18 organizations or networks contracted by the federal Health Care Financing Administration to collect data on all patients undergoing treatment for ESRD and to conduct quality assurance activities related to the care of ESRD patients.

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