Study finds growing burden of diabetes-related chronic kidney disease

Chronic kidney disease (CKD) is common, largely silent, and serious. Most people who have the condition do not realize they have it, while it sharply raises the risk of heart attacks, strokes, kidney failure and early death. Over the past decade, the share of American adults living with CKD has remained consistent. Roughly one in seven U.S. adults - about 15% - had CKD in 2013, and approximately 1 in 7 still had it in 2023. What has changed is the type of kidney disease.

In a new study, researchers have found that the proportion of Americans with kidney disease driven by diabetes rose from 4.7% to 5.7% (about a 30% relative increase), while kidney disease not linked to diabetes held steady.

"Our study reveals a concerning trend in the United States, where CKD is increasingly associated with diabetes. This is the first CKD study to utilize the recently released survey data spanning a decade, encompassing the period during which the first therapies specifically approved to protect the kidneys, namely SGLT2 inhibitors and finerenone (a nonsteroidal mineralocorticoid receptor antagonist (MRA) that mitigates the risk of kidney failure), were introduced into the market. Remarkably, despite these advancements, overall CKD rates have remained stagnant. This finding underscores the urgent need for further research and intervention to address the escalating burden of CKD in the context of diabetes," says

corresponding author Ashish Verma, MBBS, assistant professor of medicine at Boston University Chobanian & Avedisian School of Medicine.

The researchers analyzed records of 25,106 adults (aged 20 and older) from 2013 to 2023 in the National Health and Nutrition Examination Survey, a rolling government study that brings a representative sample of Americans to exam centers for interviews, physical measurements, blood, and urine tests. For every participant, they ran two kidney tests. The first, from a blood sample, measures how well the kidneys are filtering waste (estimated glomerular filtration rate, or eGFR). The second, from a urine sample, measures whether protein is leaking through the kidneys (urine albumin-to-creatinine ratio). Anyone with an abnormal result on either test was classified as having CKD. They then tracked how the rate of CKD changed over ten years - overall, and within groups defined by age, sex, race and ethnicity, income, and conditions like diabetes, high blood pressure, obesity, and heart disease.

In addition to the increasing cases of diabetes-induced CKD, researchers found the incidence gap between people with lower and higher educational attainment had widened, suggesting that social and economic circumstances, not just biology, help determine who develops kidney disease. Furthermore, CKD in men appears to be inching upward while the rate in women has held steady. Additionally, Black Americans continue to have CKD rates close to one in five - substantially higher than white Americans - with no narrowing over the 10 years.

According to the researchers, the shift in which CKD in the context of diabetes is increasing may suggest that a growing proportion of the population is at risk for progressive cardiovascular-kidney-metabolic syndrome. "What we're seeing is that kidney disease no longer travels alone. About one in four Americans with heart disease also has CKD, and the links between kidney disease, heart failure, and diabetes are getting stronger, not weaker. This is what the American Heart Association now calls cardiovascular-kidney-metabolic syndrome, and it means single-organ care isn't enough," adds first author Sophie Claudel, MD, clinical instructor of nephrology at BU and a nephrology resident at Boston Medical Center.

These findings appear online in the New England Journal of Medicine.