Trends in Incidence of ESKD in People With Type 1 and Type 2 Diabetes in Australia, 2002-2013

doi:10.1053/j.ajkd.2018.10.005

American Journal of Kidney Diseases

Volume 73, Issue 3, March 2019, Pages 300-308

https://doi.org/10.1053/j.ajkd.2018.10.005 Get rights and content

Rationale & Objective

The number of people with diabetes and end-stage kidney disease (ESKD) is increasing worldwide, but it is unknown whether this indicates an increasing risk for ESKD in people with diabetes. We examined temporal trends in the incidence of ESKD within the Australian population with diabetes from 2002 to 2013.

Study Design

Follow-up study using a national health care services registry.

Setting & Participants

Registrants with type 1 or type 2 diabetes in Australia’s National Diabetes Services Scheme (NDSS).

Predictors

Age, sex, indigenous status, diabetes type, and calendar year.

Outcome

Incidence of ESKD (dialysis or kidney transplantation) or death ascertained using the Australian and New Zealand Dialysis and Transplant Registry and the Australian national death index.

Analytical Approach

NDSS registrants were followed up from 2002 or date of registration until onset of ESKD, death, or December 31, 2013. The incidence of ESKD in type 1 diabetes was calculated only in those younger than 55 years.

Results

Among 1,375,877 registrants between 2002 and 2013, a total of 9,977 experienced incident ESKD, representing an overall incidence of ESKD in people with diabetes of 10.0 (95% CI, 9.8-10.2) per 10,000 person-years. Among those with type 1 diabetes, the age-standardized annual incidence was stable during the study period. Among those with type 2 diabetes, the incidence increased in nonindigenous people (annual percentage change, 2.2%; 95% CI, 0.4%-4.1%) with the greatest increases in those younger than 50 and those older than 80 years. No significant change over time was observed in indigenous people, although the adjusted incident rate ratio for indigenous versus nonindigenous was 4.03 (95% CI, 3.68-4.41).

Limitations

Lack of covariates such as comorbid conditions, medication use, measures of quality of care, and baseline kidney function.

Conclusions

The age-standardized annual incidence of ESKD increased in Australia from 2002 to 2013 for nonindigenous people with type 2 diabetes but was stable for people with type 1 diabetes. Efforts to prevent the development of ESKD, especially among indigenous Australians and those with early-onset type 2 diabetes, are warranted.

Graphical Abstract

Section snippets

Data Sources

The NDSS was established in 1987 by the Australian government to provide testing strips, syringes, and needles at subsidized prices to people with diabetes; 80% to 90% of all people with diabetes in Australia are listed on the registry.¹² Registration of patients is completed by a medical practitioner or accredited diabetes nurse educator.

In this study, we included people with T1DM and T2DM who were listed on the NDSS between 2002 (data quality was a problem before 2002) and 2013, including all

Participant Characteristics

A total of 93,003 individuals with T1DM and 1,282,874 individuals with T2DM were included in this analysis. Their characteristics are described in Table 1.

Incidence of ESKD in People With Diabetes

Between 2002 and 2013, a total of 9,977 incident ESKD cases (who underwent either dialysis therapy or preemptive kidney transplantation) occurred during 10,017,538 person-years of follow-up. The overall crude incidence of ESKD in people with diabetes was 10.0 (95% CI, 9.8-10.2) per 10,000 person-years. Crude incidence rates were 16.4 and 9.1

Discussion

In this national registry–based study, we showed that for T1DM, the age-standardized annual incidence of ESKD was stable between 2002 and 2013, but increased in all T2DM during the 12 years, driven mainly by those nonindigenous people with T2DM younger than 50 and older than 80 years as well as by an increase in the registration rate in the indigenous population with T2DM. Further, we showed that ESKD incidence was higher in males than females, indigenous people than nonindigenous people, most

Article Information

Authors’ Full Names and Academic Degrees

Digsu N. Koye, PhD, Dianna J. Magliano, PhD, Christopher M. Reid, PhD, Meda E. Pavkov, PhD, Steven J. Chadban, PhD, Stephen P. McDonald, PhD, Kevan R. Polkinghorne, PhD, Sarah White, PhD, Christine Paul, PhD, and Jonathan E. Shaw, MD.

Authors’ Contributions

Research idea and study design: DNK, DJM, JES; data acquisition: DNK, DJM, JES; data analysis/interpretation: DNK, DJM, CMR, MEP, SJC, SPM, KRP, SW, CP, JES; statistical analysis: DNK, DJM; supervision or mentorship: DJM, CMR, JES. Each author contributed important

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Cited by (27)

Trends in the Incidence of End-Stage Kidney Disease in Type 1 and Type 2 Diabetes in Australia, 2010-2019
2023, American Journal of Kidney Diseases
Trends in end-stage kidney disease (ESKD) among people with diabetes may inform clinical management and public health strategies. We estimated trends in the incidence of ESKD among people with type 1 and type 2 diabetes in Australia from 2010-2019 and evaluated their associated factors.
Cohort study.
71,700 people with type 1 and 1,112,690 people with type 2 diabetes registered on the Australian National Diabetes Services Scheme (NDSS). We estimated the incidence of kidney replacement therapy (KRT) via linkage to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the incidence of KRT or death from ESKD by linking the NDSS to the ANZDATA and the National Death Index for Australia.
Calendar time, sex, age, and duration of diabetes.
Incidence of KRT and KRT or death from ESKD.
Incidence of ESKD, trends over time, and associations with factors related to these trends were modeled using Poisson regression stratified by diabetes type and sex.
The median duration of diabetes increased from 15.3 to 16.8 years in type 1 diabetes, and from 7.6 to 10.2 years in type 2 diabetes between 2010 and 2019. The incidence of KRT and KRT or death from ESKD did not significantly change over this time interval among people with type 1 diabetes. Conversely, the age-adjusted incidence of KRT and KRT or death from ESKD increased among males with type 2 diabetes (annual percent changes [APCs]: 2.52% [95% CI, 1.54 to −3.52] and 1.27% [95% CI, 0.53 2.03], respectively), with no significant change among females (0.67% [95% CI, −0.68 to 2.04] and 0.07% [95% CI, −0.81 to 0.96], respectively). After further adjustment for duration of diabetes, the incidence of ESKD fell between 2010 and 2019, with APCs of −0.09% (95% CI, −1.06 to 0.89) and −2.63% (95% CI, −3.96 to −1.27) for KRT and −0.97% (95% CI, −1.71 to −0.23) and −2.75% (95% CI, −3.62 to −1.87) for KRT or death from ESKD among males and females, respectively.
NDSS only captures 80%-90% of people with diabetes; lack of clinical covariates limits understanding of trends.
While the age-adjusted incidence of ESKD increased for males and was stable for females over the last decade, after adjusting for increases in duration of diabetes the risk of developing ESKD has decreased for both males and females.
Previous studies showed an increase in new cases of kidney failure among people with type 2 diabetes, but more recent data have not been available. Here, we report trends in the rate of kidney failure for people with type 2 diabetes from 2010 to 2019 and showed that while more people with type 2 diabetes are developing kidney failure, accounting for the fact that they are also surviving longer (and therefore have a higher chance of kidney failure) the growth in this population is not caused by a higher risk of kidney failure. Nevertheless, more people are getting kidney failure than before, which will impact health care systems for years to come.
Clinical and pathological characteristics of DKD patients with early-onset type 2 diabetes
2023, Journal of Diabetes and its Complications
In diabetic kidney disease (DKD) patients, early-onset T2DM effects on renal disease severity and outcomes remain uncertain. Herein, we aim to investigate the clinicopathological characteristics and renal outcomes in DKD patients with early-onset T2DM.
489 patients with T2DM and DKD were retrospectively recruited and classified as having early (age at onset of T2DM < 40 years) and late (age at onset of T2DM ≥ 40 years) T2DM onset, analyzing the clinical and histopathological data. The predictive value of early-onset T2DM to renal outcomes in DKD patients was analyzed by Cox's regression.
Among 489 DKD patients, 142 and 347 were classified as early and late T2DM onset, respectively. Early-onset T2DM patients exhibited worse glycaemic control (7.36 % ± 1.80 % vs. 6.86 % ± 1.57 %, P = 0.007) and more severe proteinuria (3.69 [1.55 to 7.03] vs. 1.81 [0.50 to 4.33] g/24 h, P < 0.001). Those with early-onset T2DM presented more severe glomerular lesions. In univariable Cox regression, early-onset T2DM showed a significant correlation with renal composite endpoint (HR [95%CI]: 0.56 [0.43 to 0.73], P < 0.001). However, after adjusting for potential confounders, early-onset T2DM was not independently correlated with renal composite endpoint (HR [95%CI]: 0.74 [0.46 to 1.21], P = 0.232).
In DKD patients with early-onset T2DM, renal clinicopathological manifestations were severe. Age at onset in T2DM was significantly correlated with eGFR slope (r = 0.211, P < 0.001).
Targeting Diabetes Prevention to More Disadvantaged Groups Improves Cost-Effectiveness: Implications of Inequality in Type 2 Diabetes From Theoretical Interventions
2023, Value in Health
To determine the effect of socioeconomic status on efficacy and cost thresholds at which theoretical diabetes prevention policies become cost-effective.
We designed a life table model using real-world data that captured diabetes incidence and all-cause mortality in people with and without diabetes by socioeconomic disadvantage. The model used data from the Australian diabetes registry for people with diabetes and the Australian Institute of Health and Welfare for the general population. We simulated theoretical diabetes prevention policies and estimated the threshold at which they would be cost-effective and cost saving, overall, and by socioeconomic disadvantage, from the public healthcare perspective.
From 2020 to 2029, 653 980 people were projected to develop type 2 diabetes, 101 583 in the least disadvantaged quintile and 166 744 in the most. Theoretical diabetes prevention policies that reduce diabetes incidence by 10% and 25% would be cost-effective in the total population at a maximum per person cost of Australian dollar (AU$) 74 (95% uncertainty interval: 53-99) and AU$187 (133-249) and cost saving at AU$26 (20-33) and AU$65 (50-84). Theoretical diabetes prevention policies remained cost-effective at a higher cost in the most versus least disadvantaged quintile (eg, a policy that reduces type 2 diabetes incidence by 25% would be cost-effective at AU$238 [169-319] per person in the most disadvantaged quintile vs AU$144 [103-192] in the least).
Policies targeted at more disadvantaged populations will likely be cost-effective at higher costs and lower efficacy compared to untargeted policies. Future health economic models should incorporate measures of socioeconomic disadvantage to improve targeting of interventions.
Clinical perspective—evolving evidence of mineralocorticoid receptor antagonists in patients with chronic kidney disease and type 2 diabetes
2022, Kidney International Supplements
Chronic kidney disease (CKD) in type 2 diabetes is a large and growing problem leading to end-stage kidney disease, atherosclerotic cardiovascular disease, and heart failure (HF). Aldosterone is a key risk factor in promoting inflammation and fibrosis, which causes cardiorenal failure. Treatment with angiotensin-converting enzyme inhibitors or angiotensin receptor blockers does not prevent overactivation of the mineralocorticoid receptor. Therapeutic options and challenges with blocking MR overactivation by aldosterone are reviewed herein. Whereas classic steroidal mineralocorticoid receptor antagonists (MRAs) reduced albuminuria in short-term studies of diabetic and nondiabetic CKD, long-term studies evaluating hard endpoints such as loss of kidney function were not conducted in CKD because of side effects (primarily hyperkalemia). Novel nonsteroidal MRAs reduce proteinuria and markers of HF, with lower risk of hyperkalemia and without renal impairment, in comparison to steroidal MRAs. Furthermore, recent clinical trials have demonstrated the efficacy of the novel, selective, nonsteroidal MRA finerenone to delay progression of kidney and cardiovascular disease, including HF, in patients with CKD and type 2 diabetes. Concomitantly, the safety profile of finerenone is good, with few patients discontinuing treatment because of hyperkalemia, even among study participants with a low estimated glomerular filtration rate (>25 ml/min per 1.73 m²). Novel nonsteroidal MRAs such as finerenone hold the potential to be an attractive addition to the treatment paradigm in the management of patients with CKD and type 2 diabetes, targeting the unmet need of managing increased inflammation and fibrosis attributable to MR overactivation.
Young adult onset type 2 diabetes versus type 1 diabetes: Progression to and survival on renal replacement therapy
2021, Journal of Diabetes and its Complications
Citation Excerpt :
Whether these findings are consistent across different ethnicities remains to be established. In the Australian setting, a linkage study of data from the National Diabetes Services Scheme, the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and the National Death Index (NDI), examined trends in the incidence of ESKD within Australia (2002−2013).15 While no explicit comparison of age-matched cohorts of YT1DM and YT2DM was made, the annual incidence of ESKD in type 1 diabetes (age < 40 years) remained relatively stable at 8–10 cases/10,000 person-years while the annual incidence of ESKD in non-indigenous type 2 diabetes (age < 50 years) increased from 3 to 5 cases/10,000 person-years between 2002 and 2013.
Young-onset type 2 diabetes is an aggressive disease characterized by development of diabetic complications, including nephropathy, early in the disease course. However, within the cohort of young-onset type 1 and type 2 diabetes there are limited comparative data regarding progression to ESKD requiring renal replacement therapy or renal-related death (RRT/RRD).
Probabilistic linkage of data from the RPAH Diabetes Centre, National Death Index and Australian and New Zealand Dialysis and Transplant Registry was undertaken. Cumulative Incidence Competing Risk and Cox Proportional Hazards Modelling approaches were utilized to examine progression to ESKD in young-onset type 1 and type 2 diabetes (age of diagnosis 15–35 years).
Unadjusted incidence rates (95% CI) of RRT/RRD in young-onset type 1 and type 2 diabetes were 3.1 (2.3–4.0) and 4.6 (3.7–5.7) per 1000 person years respectively. After adjustment for gender, ethnicity and duration of diabetes, the HR (95% CI) of RRT/RRD in young-onset type 2 diabetes was 2.0 (1.4–2.9). The HR remained higher after further adjustment for first available cholesterol, HbA1c and systolic blood pressure but not BMI. For those who progressed to RRT, prognosis was similar irrespective of diabetes type; cumulative incidence of mortality was 40% in both young-onset type 1 and type 2 diabetes after 6 years of dialysis.
Progression to RRT/RRD is greater in young-onset type 2 diabetes than in young-onset type 1 diabetes. The increased progression is associated with increased BMI. However, once ESKD is reached, individuals with young-onset type 1 and type 2 diabetes do equally poorly.
Comparison of Clinical and Social Characteristics of Canadian Youth Living With Type 1 and Type 2 Diabetes
2021, Canadian Journal of Diabetes
Citation Excerpt :
The factors contributing to renal and cardiovascular complications are also unclear. Examination of these factors is crucial, given the lifetime risk of CKD, end-stage renal disease and cardiovascular disease (CVD) in these adolescents (8–10). The Canadians Seeking Solutions and Innovations to Overcome Chronic Kidney Disease (Can-SOLVE CKD) Network (11), funded by the Canadian Institutes of Health Research through the Strategy for Patient-Oriented Research, was created to “transform treatment and care for Canadians living with or at risk for chronic kidney disease.”
Our aim in this study was to describe the clinical and social characteristics of 2 Canadian cohorts of adolescents with diabetes.
Participants from the Improving renal Complications in Adolescents with type 2 diabetes through REsearch (iCARE) study (n=322) and the Early Determinants of Cardio-Renal Disease in Youth With Type 1 Diabetes (n=199) study were compared.
Adolescents were 10 to 18 years of age (mean ± standard deviation: 14.8±2.4 years). The T2DM cohort had a shorter duration of diabetes. Both groups had glycated hemoglobin levels above target. The type 2 diabetes (T2D) cohort was comprised of predominantly Indigenous youth. The type 1 diabetes (T1D) cohort was 58.3% European/Caucasian, with a high proportion (41.7%) of visible minority groups (Afro-Caribbean, Asian/Pacific Islander, Hispanic). The prevalence of obesity, hypertension, left ventricular hypertrophy, albuminuria and hyperfiltration was higher in the T2D cohort. The T1D cohort was more socially and economically advantaged in all 4 dimensions of health inequality.
There are significant differences in clinical and social characteristics of adolescents with T2D and T1D in Canada. Both have inadequate glycemic control with evidence of onset and progression of diabetes-related complications.
L’objectif de notre étude était de décrire les caractéristiques cliniques et sociales de 2 cohortes canadiennes d’adolescents diabétiques.
Nous avons comparé les participants à l’étude Improving renal Complications in Adolescents with type 2 diabetes through REsearch (iCARE) (n = 322) et les participants à l’étude Early Determinants of Cardio-Renal Disease in Youth With Type 1 Diabetes (n = 199).
Les adolescents avaient de 10 à 18 ans (moyenne ± écart type : 14,8 ± 2,4 ans). La cohorte atteinte du diabète de type 2 (DT2) souffrait du diabète depuis moins longtemps. Les 2 groupes avaient des concentrations d’hémoglobine glyquée au-dessus des valeurs visées. La cohorte atteinte du DST2 était majoritairement composée de personnes autochtones. La cohorte atteinte du diabète de type 1 (DT1) était composée de 58,3 % d’Européens blancs, dont une forte proportion (41,7 %) de groupes des minorités visibles (Afro-Antillais, Asiatiques/insulaires du Pacifique, Hispaniques). La prévalence de l’obésité, de l’hypertension, de l’hypertrophie ventriculaire gauche, de l’albuminurie et de l’hyperfiltration était plus élevée dans la cohorte atteinte du DT2. La cohorte atteinte du DT1 était plus socialement et économiquement favorisée dans les 4 dimensions des inégalités en santé.
Il existe des différences significatives entre les caractéristiques cliniques et sociales des adolescents atteints du DT2 et celles des adolescents atteints du DT1 au Canada. Les 2 cohortes ont une mauvaise régulation de la glycémie qui se manifeste par l’apparition et la progression des complications liées au diabète.

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Original InvestigationTrends in Incidence of ESKD in People With Type 1 and Type 2 Diabetes in Australia, 2002-2013

Rationale & Objective

Study Design

Setting & Participants

Predictors

Outcome

Analytical Approach

Results

Limitations

Conclusions

Graphical Abstract

Section snippets

Data Sources

Participant Characteristics

Incidence of ESKD in People With Diabetes

Discussion

Article Information

Authors’ Full Names and Academic Degrees

Authors’ Contributions

Adv Chronic Kidney Dis

J Formos Med Assoc

Lancet Diabetes Endocrinol

Aust NZ J Public Health

Am J Kidney Dis

Kidney Int Suppl

Lancet Diabetes Endocrinol

Age-specific trends from 2000-2011 in all-cause and cause-specific mortality in type 1 and type 2 diabetes: a cohort study of more than one million people

Diabetes Care

Mortality trends in patients with and without diabetes in Ontario, Canada and the UK from 1996 to 2009: a population-based study

Diabetologia

Reduced incidence of lower-extremity amputations in people with diabetes in Scotland: a nationwide study

Diabetes Care

Reduction in diabetes-related lower-extremity amputations in the Netherlands: 1991-2000

Diabetes Care

Changes in diabetes-related complications in the United States, 1990-2010

N Engl J Med

Increases in renal replacement therapy in Australia and New Zealand: understanding trends in diabetic nephropathy

Nephrology (Carlton)

Chapter 1: Incidence of end stage kidney disease. In: 39th Report

US Renal Data System 2017 Annual Data Report: epidemiology of kidney disease in the United States

Am J Kidney Dis

Diabetes prevalence in Australia: an assessment of national data sources. In: Diabetes Series

Information Paper: Census of Population and Housing. Socio-Economic Indexes for Areas

New primary renal diagnosis codes for the ERA-EDTA

Nephrol Dial Transplant

Cancer risk among people with type 1 and type 2 diabetes: disentangling true associations, detection bias, and reverse causation

Diabetes Care

Permutation tests for joinpoint regression with applications to cancer rates

Stat Med

Original Investigation
Trends in Incidence of ESKD in People With Type 1 and Type 2 Diabetes in Australia, 2002-2013