Research Article: Evidence of chronic kidney disease in veterans with incident diabetes mellitus

Date Published: February 9, 2018

Publisher: Public Library of Science

Author(s): Justin Gatwood, Marie Chisholm-Burns, Robert Davis, Fridtjof Thomas, Praveen Potukuchi, Adriana Hung, Csaba P. Kovesdy, Gianpaolo Reboldi.


While chronic kidney disease (CKD) is regularly evaluated among patients with diabetes, kidney function may be significantly impaired before diabetes is diagnosed. Moreover, disparities in the severity of CKD in such a population are likely. This study evaluated the extent of CKD in a national cohort of 36,764 US veterans first diagnosed with diabetes between 2003 and 2013 and prior to initiating oral antidiabetic therapy. Evidence of CKD (any stage) at the time of diabetes diagnosis was determined using eGFR and urine-albumin-creatinine ratios, the odds of which were assessed using logistic regression controlling for patient characteristics. CKD was evident in 31.6% of veterans prior to being diagnosed with diabetes (age and gender standardized rates: 241.8 per 1,000 adults [overall] and 247.7 per 1,000 adult males), over half of whom had at least moderate kidney disease (stage 3 or higher). The odds of CKD tended to increase with age (OR: 1.88; 95% CI: 1.82–1.93), hemoglobin A1C (OR: 1.05; 95% CI: 1.04–1.06), systolic blood pressure (OR: 1.04; 95% CI: 1.027–1.043), and BMI (OR: 1.016; 95% CI: 1.011–1.020). Both Asian Americans (OR: 1.53; 95% CI: 1.15–2.04) and African Americans (OR: 1.11; 95% CI: 1.03–1.20) had higher adjusted odds of CKD compared to whites, and prevalence was highest in the Upper Midwest and parts of the Mid-South. Results suggest that evidence of CKD is common among veterans before a diabetes diagnosis, and certain populations throughout the country, such as minorities, may be afflicted at higher rates.

Partial Text

Approximately 10% of the general US population, more than 20 million people, has chronic kidney disease (CKD), and this condition is especially prevalent among patients with diabetes mellitus (DM) [1]. Specifically, an estimated one-third of adults with DM has CKD, and DM is the leading cause of CKD and end stage renal disease (ESRD) [1,2]. Several subgroups of the population, such as African Americans and Hispanics, experience higher rates or faster progression of CKD, and geographical variation in the prevalence of this condition has been suggested, although data on regional differences remain limited [3–6].

Out of the original cohort of 187,349 veterans, 36,764 remained eligible after considering the requisite lab values needed for this analysis. Across all patients included, mean eGFR was 78.5 mL/min/1.73 m2 (SD: 18.46) and median UACR was 8.1 mL/min/1.73 m2 (IQR: 4.1–20.7), and a higher proportion of patients with CKD were on either an angiotensin converting enzyme (ACE) inhibitor or an angiotensin II receptor blocker (ARB) by the time they were diagnosed with diabetes (p<0.0001). However, most patients with CKD were not on either therapy, irrespective of stage, and the proportion of patients on an ACE or ARB was markedly different based on year of diagnosis. Beginning in 2005, at least 31% of all patients (regardless of whether they had evidence of CKD) were on either therapy, but the proportion of those on an ACE or ARB remained consistently higher among patients with any stage of CKD, year-over-year. Table 1 describes the full characteristics of the sample. Using data from the nationwide VA electronic health record system, we observed that among veterans who were eventually diagnosed with DM nearly one-third of them had evidence of CKD by the time of their initial DM diagnosis. Most of these patients had early stages of CKD (low grade albuminuria and/or mildly decreased eGFR). Similar to the general US population, significant racial disparities in the prevalence and severity of CKD were observed when adjusting for multiple patient characteristics. Additionally, some regional variation in CKD prevalence was noted, and several areas of the country had a particularly high number of cases.   Source: