CLINICAL KIDNEY JOURNAL

Clinical Kidney Journal, 2016, vol. 9, no. 3, 454456

doi: 10.1093/ckj/sfw029
Advance Access Publication Date: 24 May 2016
Editorial Comment

EDITORIAL COMMENT

Diabetes mellitus as a cause of end-stage renal disease in Europe:

signs of improvement
Jan A.J.G. van den Brand
Department of Nephrology, Radboud Institute for Health Science, Radboud University Medical Center, Nijmegen,
The Netherlands
Correspondence and offprint requests to: Jan A.J.G. van den Brand; E-mail: jan.vandenbrand@radboudumc.nl

The ERA-EDTA Registry is an international collaboration collecting data on renal replacement therapy (RRT) in Europe and countries bordering the Mediterranean Sea via national and
international registries. The data are used for focused scientic
studies on specic questions and for epidemiological surveillance of the state of RRT in Europe, which is evaluated annually
and presented in the traditional ERA-EDTA Registry Reports. In
this issue of the Clinical Kidney Journal, Kramer et al. [1] provide a
summary of the 2013 ERA-EDTA Registry Annual Report. At present, the ERA-EDTA Registry covers 49 registries in 34 countries.
Almost two-thirds of these registries offer individual patient
data. The summary focused on diabetes mellitus (DM) as a
cause of end-stage renal disease (ESRD) requiring RRT.
Diabetes is an important health concern. The estimated
prevalence rate of diabetes in Europe was 8.5% in 2013 and is projected to increase to 10.3% in 2035 [2] (Figure 1). It is one of the
main underlying causes of death in adults, accounting for 10%
of all deaths in Europe [3]. Furthermore, persons who have diabetes in addition to chronic kidney disease have an 50% higher
risk of ESRD and death than those at a similar level of estimated
glomerular ltration rate [4]. Therefore, it is an important contributor to RRT in Europe. In total, 477 186 persons in Europe
were receiving RRT in 2013. This amounts to an overall prevalence
rate of 738 patients per million population in Europe and the Mediterranean, and 17% of these patients had DM as the primary cause
of kidney disease. The average incidence rate of RRT in 2013 was
122 persons per million population who started RRT in 2013 in
the ERA-EDTA Registry area. About 24% of the incident RRT
cases had DM as the primary cause of their kidney disease. One
immediately notes the marked difference between the proportion
of incident RRT cases due to DM and the proportion of prevalent
RRT patients with DM. The authors report a markedly poorer 5year survival rate on RRT of 50.6% for patients who had DM as

the primary kidney disease when compared with the overall 5year survival rate on RRT of 60.9%. Fortunately, evaluation of
more recent short-term survival sends a more uplifting message:
the overall 2-year survival rate on RRT has improved from 81.4%
between 2004 and 2008 to 82.7% between 2007 and 2011. This
improved survival rate was even more pronounced in patients
who suffered from ESRD requiring RRT due to diabetes: from
77.3% between 2004 and 2008 to 79.4% between 2007 and 2011.
Even more remarkably were the trends in incidence of RRT
due to DM over the past decade. Despite a decreasing incidence
of DM, its prevalence rate has steadily increased over the past
few decades and is projected to increase even further in the
two decades to come [2, 6]. Given the substantial proportion of
patients with DM who develop chronic kidney disease and ultimately ESRD, one would expect the incidence of RRT as a consequence of DM to increase as well. However, Kramer et al. [1]
show that the incidence of RRT has remained stable over the
past 10 years, even trending towards a slight decrease in recent
years (see Figure 3 of their paper). They made a similar observation on data from the United States Renal Data System (USRDS).
These results mean that the prevention of chronic kidney disease
secondary to DM has improved, at least for Western countries.
Still, the incidence of RRT secondary to DM was ve times
higher in the USA compared with Europe, whereas that of RRT
due to other causes of kidney disease was two times higher.
This may indicate that the progression of CKD to ESRD due to
DM is far greater in the USA compared with Europe. One may
speculate about underlying causes, which could include (i) differences in the management of ESRD, (ii) differences in genetic
background, particularly in African Americans and (iii) differences in the prevalence of risk factors for progressive kidney
damage. A study by van de Luijtgaarden et al. [8] indicated that
nephrologists in high RRT incidence countries were more likely

Received: February 17, 2016. Accepted: March 28, 2016

The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/
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Editorial Comment

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diabetic patients seems to be working, thus curbing the expected

increase in ESRD due to DM. However, despite stabilizing DM incidence in recent years [17], the peak in DM prevalence is still to
come as persons with DM live longer than before. Continued effort is needed to address the underlying causes of diabetes and
diabetic nephropathy at a population level. We seem to have
won the rst battle in the ght against ESRD due to diabetes,
but the war is far from over.

Acknowledgements
J.A.J.G.v.d.B. is supported by a grant from the Dutch Kidney Foundation (DKF14OKG07).

Fig. 1. Trends in diabetes prevalence and forecasted prevalence of diabetes in

Europe. The black line represents the observed prevalence of diabetes over

(See related article by Kramer et al. Renal replacement therapy in

Europe: a summary of the 2013 ERA-EDTA Registry Annual Report
with a focus on diabetes mellitus. Clin Kidney J (2016) 9: 457469.)

time. The dotted, grey line is the forecasted prevalence. Data from Shaw et al.
[5], Danaei et al. [6], Whiting et al. [7] and Guariguata et al. [2].

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