Eli A Friedman

Throughout the industrialized world, diabetes mellitus is the leading cause of end-stage renal disease (ESRD), surpassing glomerulonephritis and hypertension. Both the incidence and the prevalence of ESRD caused by diabetes have risen each year over the past decade, according to reports from European, Japanese, and North American registries of patients with renal failure. Illustrating the dominance of diabetes in ESRD is the 1997 report of the United States Renal Data System (USRDS), which noted that of 257,266 patients receiving either dialytic therapy or a kidney transplant in 1995 in the United States, 80,667 had diabetes [1], a prevalence rate of 31.4%. Also, during 1995 (the most recent year for which summa-tive data are available), of 71,875 new (incident) cases of ESRD, 28,740 (40%) patients were listed as having diabetes.

In America, Europe, and Japan, the form of diabetes is predominantly type II; fewer than 8% of diabetic Americans are insulinopenic, C-peptide-negative persons with type I disease. It follows that ESRD in diabetic persons reflects the demographics of diabetes per se [2]: 1) The incidence is higher in women [3], blacks [4], Hispanics [5], and native Americans [6]. 2) The peak incidence of ESRD occurs from the fifth to the seventh decade. Consistent with these attack rates is the fact that blacks older than the age of 65 face a seven times greater risk of diabetes-related renal failure than do whites. Within our Brooklyn and New York state hospital ambulatory hemodialysis units in October 1997, 97% of patients had type II diabetes. Despite widespread thinking to the contrary, vasculopathic complications of diabetes, including hypertension, are at least as severe in type II as in type I diabetes [7,8]. When carefully followed over a decade or longer, cohorts of type I and type II diabetic individuals have equivalent rates of proteinuria, azotemia, and ultimately ESRD. Both types of diabetes show strong similarities in their rate of renal functional deterioration [9] and onset of comorbid complications. Initial nephromegaly as well as both glomerular hyperfiltration and microalbuminuria (previously thought to be limited to type I) is now recognized as equally in type II [10].

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