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End-Stage Renal Disease Attributable to Diabetes Mellitus

Thomas V. Perneger, MD, PhD; Frederick L. Brancati, MD, MHS; Paul K. Whelton, MD, MSc; and Michael J. Klag, MD, MPH
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From The Johns Hopkins University School of Hygiene and Public Health and School of Medicine, Baltimore, Maryland; and the University of Geneva, Geneva, Switzerland. Requests for Reprints: Thomas V. Perneger, MD, PhD, Institute of Social and Preventive Medicine, University of Geneva, CMU Case Postale, 1211 Geneva 4, Switzerland. Acknowledgments: The authors thank Shirley Kritt, Tamra Myers, and Jennifer Sykes for their technical assistance and acknowledge the contributions of collaborators at the Health Care Financing Administration (Zermain Breidenbaugh, Paul Eggers, Pamela Frederick, Michael McMullan, Paul Mendelsohn, and Izzy Oppenheimer) and the Mid-Atlantic Renal Coalition (Nancy Armistead and Arlene Skinner). Grant Support: By grants from the Swiss National Science Foundation (823B-025121 and 32-32609), the Schmidheiny Foundation, the American Heart Association, the National Kidney Foundation, the Agency for Health Care Policy and Research (R03 HS 06978-01), GCRC grants (5MOIRR00722 and RR00035) from the National Center for Research Resources, and a Health of the Public Award from the Pew Charitable Trusts and Robert Wood Johnson Foundation. Dr. Brancati is supported by a Career Development Grant from the American Diabetes Association. Dr. Klag is an Established Investigator of the American Heart Association.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1994;121(12):912-918. doi:10.7326/0003-4819-121-12-199412150-00002
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Objective: To determine the proportion of end-stage renal disease associated with diabetes mellitus in a biracial population, using population-attributable risk estimates.

Design: Case-control study.

Setting: Population-based study in Maryland, Virginia, West Virginia, and Washington, D.C.

Participants: 716 newly treated patients with kidney failure aged 20 to 64 years and 361 age-matched controls.

Measurements: Self-reported history of diabetes mellitus, including type, duration, treatment, and complications.

Results: Persons with insulin-dependent diabetes (odds ratio, 33.7) and non–insulin-dependent diabetes (odds ratio, 7.0) were at greater risk for end-stage renal disease than were persons without diabetes. The odds ratio was only slightly increased for diabetes lasting less than 15 years, but the ratio increased more than 20-fold for diabetes lasting 15 years or more. The population-attributable risk for kidney failure was 21% for insulin-dependent diabetes and 21% for non–insulin-dependent diabetes (42% overall). A similar proportion of end-stage renal disease was attributed to diabetes in whites (44%) and in blacks (41%). Insulin-dependent diabetes had a relatively greater effect on the incidence of kidney failure in whites; in contrast, non–insulin-dependent diabetes had a relatively greater effect on kidney failure in blacks.

Conclusions: Diabetes mellitus has a major effect on the incidence of end-stage renal disease in nonelderly adults. In black persons, diabetes may be responsible for a larger proportion of end-stage renal disease than is suggested by the use of clinical diagnoses of underlying renal disease made by patients' nephrologists. Prevention of end-stage renal disease associated with diabetes mellitus (both insulin-dependent and non–insulin-dependent diabetes) requires increased attention from laboratory and clinical researchers.


Grahic Jump Location
Figure 1.
Decision algorithm for distinguishing between insulin-dependent and non–insulin-dependent diabetes.

The algorithm was applied to 357 participants with diabetes from the case–control study of end-stage renal disease in Maryland, Virginia, West Virginia, and Washington, D.C., in 1991.

Grahic Jump Location
Grahic Jump Location
Figure 2.
Odds ratios for end-stage renal disease of any cause for duration of diabetes.

Data are from the case–control study done in Maryland, Virginia, West Virginia, and Washington, D.C., in 1991 (univariate analysis).

Grahic Jump Location




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