End-Stage Renal Disease Associated
with Diabetes -- United States, 1988
End-stage renal disease (ESRD) is a major complication of diabetes
and
requires dialysis or transplantation for survival. The Medicare
program
provides reim bursement* for greater than 90% of ESRD treatment in
the
United States and maintains information that provides a basis for
surveillance of ESRD (1). In 1987, 33,393 new cases of ESRD were
reported to Medicare, of which 9482 (28.4%) were attributed to
diabetes. Previous studies indicate that the age-adjusted incidence
of
diabetes-attributable ESRD is three to seven times higher among
blacks,
American Indians, and Mexican Americans than among whites (2,3).
Of the 18,854 ESRD cases reported to Medicare in January-June
1988,
4535 (24.1%) were attributed to diabetes: 2577 (56.8%) to
adult-onset**
type, 1836 (40.5%) to juvenile type, and 122 (2.7%) unclassified.
ESRD
was more commonly attributed to adult-onset diabetes among blacks
(62.5%), Asians (67.7%), and American Indians (78.7%) than among
whites
(55.8%).
ESRD cases attributed to adult-onset diabetes were most frequent
in
older age groups (Figure 1). ESRD cases attributed to juvenile
diabetes
are characterized by a bimodal distribution (Figure 1). However,
because many noninsulin-dependent diabetes mellitus (NIDDM)
patients
are treated with insulin, they are often misclassified in surveys
as
insulin-dependent diabetes mellitus (IDDM) patients. This may
account
for the apparent increase in juvenile-diabetes-related ESRD cases
in
older age groups.
Reported by: Bur of Data Management and Strategy, Health Care
Financing
Administration. Div of Diabetes Translation, Center for Chronic
Disease
Prevention and Health Promotion, CDC.
Editorial Note
Editorial Note: Adult-onset diabetes accounts for most
diabetes-related
ESRD in the United States, especially among minority populations.
The
Medicare data are consistent with findings from medical record
reviews
in Nebraska (4), Michigan (5), and a large health-maintenance
organization (6). Refinement of the classification of type of
diabetes
and evaluation of its precision would increase the value of the
Medicare information system for surveillance of ESRD associated
with
diabetes.
Control of hyperglycemia and hypertension are recommended for
preventing and slowing the progression of diabetes-associated renal
disease (7). These interventions are emphasized in state and
territorial diabetes-control programs and in public and
professional
education programs initiated by the American Diabetes Association
and
the National Kidney Foundation. Close monitoring for early markers
of
renal disease can identify persons at high risk for ESRD and allow
targeting of dietary and pharmacologic interventions. Additional
study
of the application of these measures is being supported by the
National
Institute of Diabetes and Digestive and Kidney Diseases (8).
Chronic disease control programs should consider prevention of
NIDDM
as an additional approach to reduce ESRD and other complications of
diabetes (9,10). Effective dietary and physical activity approaches
are
urgently needed, especially for families predisposed to NIDDM and
for
high-risk populations (e.g., blacks, American Indians, and Mexican
Americans).
References
Eggers PW, Connerton R, McMullan M. The Medicare experience with
end-stage renal disease: trends in incidence, prevalence, and
survival.
Health Care Financ Rev 1984;5:69-88.
Teutsch S, Newman J, Eggers P. The problem of diabetic renal
failure
in the United States: an overview. Am J Kidney Dis 1989;13:11-3.
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.
Rettig B, Teutsch SM. The incidence of end-stage renal disease
in
type I and type II diabetes mellitus. Diabetic Nephropathy
1984;3:26-7.
Cowie CC, Port FK, Wolfe RA, Savage PJ, Moll PP, Hawthorne VM.
Racial differences in diabetic end-stage renal disease incidence by
diabetic type (Abstract). Diabetes 1988; 37(suppl 1):52A.
Ordonez JD, Hiatt RA. Comparison of type II and type I diabetics
treated for end-stage renal disease in a large prepaid health plan
population. Nephron 1989;51:524-9.
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.
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.
Tuomilehto J, Wolf E. Primary prevention of diabetes mellitus.
Diabetes Care 1987;10: 238-48.
CDC. Community-based exercise intervention--the Zuni Diabetes
Project. MMWR 1987;36: 661-4.
*More than $3 billion for the care of approximately 147,000 persons
in
1987.
**In 1988, diabetes-attributable ESRD was subclassified by
treatment
providers into "adult-onset" and "juvenile" types (the nomenclature
of
the International Classification of Diseases, Ninth Revision
(ICD-9))
without explicit criteria. Although these categories cannot be
directly
translated into the preferred categories of noninsulin-dependent
diabetes mellitus and insulin-dependent diabetes mellitus,
respectively, they allow some assessment of the contributions of
the
two major types of diabetes to ESRD.
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