Incidence of End-Stage Renal Disease Attributed to Diabetes Among Persons With Diagnosed Diabetes --- United States and Puerto Rico, 1996--2007

Incidence of End-Stage Renal Disease Attributed to Diabetes Among Persons With Diagnosed Diabetes --- United States and Puerto Rico, 1996--2007
Weekly
October 29, 2010 / 59(42);1361-1366

During 2007, approximately 110,000 persons in the United States and Puerto Rico began treatment for end-stage renal disease (ESRD) (i.e., kidney failure requiring dialysis or transplantation) (1). Diabetes is the leading cause of ESRD in the United States, accounting for 44% of new cases in 2007 (1). Although the number of persons initiating treatment for kidney failure each year who have diabetes listed as a primary cause (ESRD-D) has increased since 1996 (1,2), ESRD-D incidence among persons with diagnosed diabetes has declined since 1996 (3). To determine whether this decline occurred in every U.S. region and in every state, CDC analyzed 1996--2007 data from the U.S. Renal Data System (USRDS) and the Behavioral Risk Factor Surveillance System (BRFSS). During the period, the age-adjusted rate of ESRD-D among persons with diagnosed diabetes declined 35% overall, from 304.5 to 199.1 per 100,000 persons with diagnosed diabetes, and declined in all U.S. regions and in most states. No state showed a significant increase in the age-adjusted ESRD-D rate. Continued awareness of risk factors for kidney failure and interventions to improve diabetes care are needed to sustain and improve these trends.

USRDS collects, analyzes, and distributes ESRD clinical and claims data to the Centers for Medicare and Medicaid Services (CMS) (1). Health-care providers are required by law to complete the CMS Medical Evidence Report for each new patient with ESRD. USRDS collects demographic data and ESRD-related information (e.g., date patients were first treated, diagnosed primary cause of renal failure). The USRDS Renal Data Extraction and Referencing System, an online data querying application, was used to determine the number of persons initiating ESRD treatment (i.e., dialysis or transplantation) with diabetes listed as a primary cause in each state, the District of Columbia (DC), and Puerto Rico for each of the years during 1996--2007. Throughout the period, the proportion of new ESRD cases that were ESRD-D ranged from 43% to 45% (1). Incidence of ESRD-D was calculated at a state/territorial and U.S. census region level by dividing the number of persons with a new diagnosis of ESRD-D in the geographic unit (determined by their initiation of treatment) by the estimated number of persons with diagnosed diabetes in the geographic unit. The number of persons aged ≥18 years with diagnosed diabetes was estimated from BRFSS, which conducts state-based, random-digit--dialed telephone surveys in the 50 states, DC, Puerto Rico, and other U.S. territories. In 2007, the median BRFSS response rate was 50.6% (range: 26.9%--65.4%) for the 50 states and DC and 70.4% for Puerto Rico.

Respondents were classified as having diagnosed diabetes if they answered "yes" to the question "Has a doctor ever told you that you have diabetes?" Women who were told that they had diabetes only during pregnancy were classified as not having diabetes. BRFSS data were weighted to represent the noninstitutionalized U.S. population. Data were analyzed using statistical software to estimate standard errors and calculate 95% confidence intervals (CIs). Incidence was age adjusted directly to the 2000 U.S. standard population, and weighted least squares regression was used for state and regional-level trend analyses. Linear and quadratic terms were included in the models, and results were considered significant if p<0.05. Nonsignificant quadratic terms were dropped from the models. Significant terms indicated a trend (i.e., linear or nonlinear) in the data over time.

During 1996--2007, the total number of adults aged ≥18 years in the United States and Puerto Rico who began treatment for ESRD-D each year increased significantly, from 32,716 (state range: 32−3,719) to 48,712 (state range: 37--6,059) (test for trend, p<0.001) (Table, Figure 1). More recently, the number of ESRD-D cases appears to be leveling off (Figure 1). During 2007, approximately 40% of the new ESRD-D cases occurred in the South, and approximately 20% occurred in each of the other three U.S. census regions (Table).* However, the rate of ESRD-D among persons with diagnosed diabetes in 2007 was significantly higher in the West (219.2 per 100,000) compared with the Northeast (182.6 per 100,000). During 1996--2007, the age-adjusted ESRD-D incidence in persons with diagnosed diabetes decreased 35%, from 304.5 per 100,000 (state range: 152.7--544.4) to 199.1 per 100,000 (state range: 108.1--450.0) (p<0.001) (Table, Figure 1). Incidence declined significantly in all U.S. regions (Figure 2). Estimated age-adjusted ESRD-D incidence declined in most states, but the trend was not significant in every state (Table). The age-adjusted ESRD-D incidence in Puerto Rico increased significantly from 1996 to 2003 (p<0.001), and decreased, but not significantly, from 2003 to 2007 (p=0.30).
Reported by

NR Burrows, MPH, I Hora, MS, P Cho, MPH, RB Gerzoff, MS, LS Geiss, MA, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

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Incidence of End-Stage Renal Disease Attributed to Diabetes Among Persons With Diagnosed Diabetes --- United States and Puerto Rico, 1996--2007