Abstract

Background
There are limited population-wide trend data on kidney failure and kidney replacement therapy (KRT) in people with diabetes. We conducted a retrospective cohort study to report incidence trends of kidney failure and KRT and related mortality in people with diabetes in Hong Kong between 2002 and 2015.

Methods
We used territory-wide electronic medical records including laboratory, diagnostic and procedural data to identify people with kidney failure and KRT. We used Joinpoint regression models to estimate the average annual percent change (AAPC) of kidney failure and KRT incidence for entire study period, and annual percent change (APC) for each linear trend segment, along with 1-year and 5-year mortality rates.

Findings
During 4.9 million person-years of follow-up of 712,222 people with diabetes, 31,425 developed kidney failure, among whom 23.0% (n=7,233) received KRT. The incidence of kidney failure declined by 46.8% from 2002 to 2007 (APC: -11.6, 95% CI: -16.3, -6.7), then flattened from 2007 to 2015 (APC: -0.9, 95% CI: -3.1, 1.3). The incidence of KRT remained constant (AAPC: -1.6, 95% CI: -4.4, 1.2). The 1-year mortality rates declined statistically significantly after both kidney failure and KRT. The 5-year mortality rates declined after kidney failure but the decline was not statistically significant after KRT.

Interpretation
The findings of our study highlight the importance of developing new strategies to prevent a looming epidemic of kidney failure in people with diabetes in Hong Kong.

۱٫ Introduction

Kidney failure is a major contributor to chronic disability, impaired quality of life and premature death in people with diabetes[1], [2], [3] . In recent estimates, between 40% and 50% of people newly initiating kidney replacement therapy (KRT) had underlying diabetes4,5 . In Hong Kong, the proportion of people entering KRT attributable to diabetes has increased from 26.2% in 1996 to 49.6% in 20136. The rapidly rising worldwide burden of diabetes in the past 20 years has contributed to increased number of people at high risk of kidney failure and related morbidity and mortality7,8. In the United States, population surveillance revealed a decline in the incidence of kidney failure with KRT in people with diabetes across a 20-year period between 1990 and 2010 which levelled off after 20109,10. In Germany, the incidence of KRT in people with diabetes was stable between 2002 and 201611, whilst that in Australia, increased between 2002 and 201312. Population-wide studies reporting trends in incidence of kidney failure among people with diabetes in Asia are sparse. Understanding the epidemiology of kidney failure in people with diabetes allows us to evaluate the quality of diabetes care, to develop approaches to primary and secondary prevention of kidney disease, and to plan health services to address unmet needs.