Diabetics With End-Stage Renal Disease

On November 3, 2017, the CDC published a report that found that, during 2014, 120,000 persons in the United States and Puerto Rico began treatment for end-stage renal disease (ESRD) (kidney failure requiring dialysis or transplantation). Among these persons, 44 percent (approximately 53,000 persons) had diabetes listed as the primary cause of ESRD (ESRD-D).


ESRD is a costly and disabling condition that often results in premature death. ESRD, also called end-stage kidney disease or stage 5 kidney disease, occurs when chronic kidney disease — the gradual loss of kidney function — reaches an advanced state requiring dialysis or a kidney transplant for the patient to survive. According to the United States Renal Data System, in the hemodialysis population, total fee-for-service Medicare expenditures per person per year were $87,945 in 2011. The best current treatment for ESRD is kidney transplantation, but this requires a donor match, major surgery, and a lifetime regimen of immunosuppressant medications to prevent rejection. The average cost of a kidney transplant is $32,000 for the transplant surgery and $25,000 per year post-surgery to care for the patient and ensure the transplant is not rejected.


Although the number of persons initiating ESRD-D treatment each year has increased since 1980, the ESRD-D incidence rate among persons with diagnosed diabetes has declined since the mid-1990s. To determine whether ESRD-D incidence has continued to decline in the United States overall and in each state, the District of Columbia (DC), and Puerto Rico, the CDC analyzed 2000 to 2014 data from the U.S. Renal Data System and the Behavioral Risk Factor Surveillance System. During that period, the age-standardized ESRD-D incidence among persons with diagnosed diabetes declined from 260.2 to 173.9 per 100,000 diabetic population (33%), and declined significantly in most states, DC, and Puerto Rico. No state experienced an increase in ESRD-D incidence rates. Continued awareness of risk factors for kidney failure and interventions to improve diabetes care might sustain and improve these trends.


Between 2000 and 2014, the total number of adults 18 years old or older in the United States, DC, and Puerto Rico who began ESRD-D treatment each year increased from 42,236 (state range = 32–5,117) to 53,382 (state range = 47–7,228). From 2000 to 2014, among 47 states, DC, and Puerto Rico, the age-standardized ESRD-D incidence decreased 33 percent, from 260.2 (state range = 171.2–569.6) to 173.9 (state range = 81.7–363.6) per 100,000 persons with diabetes. Between 2000 and 2014, rates declined significantly in most states, DC, and Puerto Rico. In Kansas and Utah, rates declined and then leveled off. From 2000 to 2014, rates did not decline significantly in California, Hawaii, Mississippi, or Montana. In 2000, the rate was 217.5 or more per 100,000 persons with diabetes in 41 states, DC, and Puerto Rico, and the rate was not less than 164.5 in any state. In 2014, the rate was 217.5 or more in five states and DC, and was less than 164.5 in 24 states. In 2014, the highest rates were in DC and Hawaii. Continued awareness and interventions to reduce the prevalence of risk factors for kidney failure, improve diabetes care, and reduce the incidence of type 2 diabetes might sustain these positive trends.


Although ESRD-D incidence rates are declining, the number of patients with newly diagnosed ESRD-D is likely to increase as the number of persons with diabetes increases. Furthermore, one in three adults with diabetes is estimated to have chronic kidney disease (i.e., kidney damage or reduced kidney function). However, most persons with chronic kidney disease are unaware that they have it. Early detection and better management of chronic kidney disease in persons with diabetes can slow its progression to ESRD, prevent complications, and improve cardiovascular outcomes. Testing for urine albumin, which is an early marker of kidney disease, is recommended for all patients with diabetes, and treatment with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers is indicated for persons with diabetes and hypertension. Effective interventions to improve blood glucose levels and blood pressure control might prevent or delay the onset of kidney disease in adults with diabetes. To support primary prevention, effective community-based approaches to prevent obesity and increase physical activity, along with type 2 diabetes prevention programs targeted to populations at high risk, might reduce the incidence of type 2 diabetes, and consequently, diabetic kidney disease.


See the CDC Report


See also Medical Law Perspectives Report: Kidney Diseases and Disorders: Stones, Dialysis, and Liability Concerns


See also Medical Law Perspectives Report: Diabetes and Its Complications: Malpractice and Other Liability Issues