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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).


  1. 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.

  2. 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.

  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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. Tuomilehto J, Wolf E. Primary prevention of diabetes mellitus. Diabetes Care 1987;10: 238-48.

  10. 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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