Vital Signs: Decrease in Incidence of Diabetes-Related End-Stage Renal Disease among American Indians/Alaska Natives - United States, 1996-2013

Abstract

Background: American Indians and Alaska Natives (AI/AN) have the highest diabetes prevalence among any racial/ethnic group in the United States. Among AI/AN, diabetes accounts for 69% of new cases of end-stage renal disease (ESRD), defined as kidney failure treated with dialysis or transplantation. During 1982-1996, diabetes-related ESRD (ESRD-D) in AI/AN increased substantially and disproportionately compared with other racial/ethnic groups.

Methods: Data from the U.S. Renal Data System, the Indian Health Service (IHS), the National Health Interview Survey, and the U.S. Census were used to calculate ESRD-D incidence rates by race/ethnicity among U.S. adults aged ≥18 years during 1996-2013 and in the diabetic population during 2006-2013. Rates were age-adjusted based on the 2000 U.S. standard population. IHS clinical data from the Diabetes Cares and Outcomes Audit were analyzed for diabetes management measures in AI/AN.

Results: Among AI/AN adults, age-adjusted ESRD-D rates per 100,000 population decreased 54%, from 57.3 in 1996 to 26.5 in 2013. Although rates for adults in other racial/ethnic groups also decreased during this period, AI/AN had the steepest decline. Among AI/AN with diabetes, ESRD-D incidence decreased during 2006-2013 and, by 2013, was the same as that for whites. Measures related to the assessment and treatment of ESRD-D risk factors also showed more improvement during this period in AI/AN than in the general population.

Conclusion and implications for public health practice: Despite well-documented health and socioeconomic disparities among AI/AN, ESRD-D incidence rates among this population have decreased substantially since 1996. This decline followed implementation by the IHS of public health and population management approaches to diabetes accompanied by improvements in clinical care beginning in the mid-1980s. These approaches might be a useful model for diabetes management in other health care systems, especially those serving populations at high risk.

FIGURE 1

Incidence of diabetes-related end-stage renal disease among adults aged ≥18 years, by race and ethnicity — United States, 1996–2013 Source: Data from the U.S. Renal Data System and the U.S. Census. Abbreviation: AI/AN=American Indians and Alaska Natives. * Rate per 100,000 population and age-adjusted based on the 2000 U.S. standard population. Racial groups include persons of Hispanic and non-Hispanic origin; Hispanics may be of any race.

FIGURE 2

Incidence of diabetes-related end-stage renal disease among adults aged ≥18 years with diabetes, by race and ethnicity — United States, 2006–2013 Sources: U.S. Renal Data System, U.S. Diabetes Surveillance System, and data from the Indian Health Service applied to the U.S. Census population. Abbreviation: AI/AN=American Indians and Alaska Natives. * Rate per 100,000 diabetic population and age-adjusted based on the 2000 U.S. standard population. Racial groups include persons of Hispanic and non-Hispanic origin; Hispanics may be of any race.

FIGURE 3

ACE Inhibitor/ARB prescription in AI/AN patients with diabetes, 1996–2015 Source: Indian Health Service Diabetes Care and Outcomes Audit. Abbreviations: ACE = angiotensin converting enzyme; AI/AN = American Indians and Alaska Natives; ARB = angiotensin receptor blocker; CKD = chronic kidney disease.