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Diabetes Prevention: The Key To Reducing End-stage Kidney Disease 

Sep 1, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Peter Jay Won, Pharm.D. Candidate, University of South Florida, Taneja College of Pharmacy 

Earlier onset of type 2 diabetes equals higher risk of kidney transplant, making diabetes delay or prevention important in reducing development of end-stage kidney disease.  

More than one in three Americans are projected to develop diabetes by 2050. One-in-three of those patients with diabetes will develop end-stage kidney disease (ESKD). ESKD is a $36 billion (2017), or nearly $80,000 annually per person, complication that often requires a transplant and life-long medication support. Unfortunately, there are only a few researchers dedicated to discovering the association between patients with diabetes and their long-term risk of ESKD development. Funding and collecting enough participants are common limiting factors. 


Nevertheless, Jedidiah I. Morton, a faculty researcher at the School of Public Health and Preventive Medicine, is one of the few. His practice at the Baker Heart and Diabetes Institute is located at Monash University, Australia. His latest publication was a response to challenge the misconception from a previous publication by Dr. Patrik Finne in the April 2019 issue of Diabetes Care, a misconception that the age of onset did not have any effect in developing ESKD. Dr. Finne’s method of selecting the participants, from Finland, concerned many researchers. A third of the total participants were diagnosed with diabetes over the age of 70, where they are doubtful to undergo a kidney transplant; while excluding people diagnosed with diabetes before the age of 40, where they are at most risk for developing ESKD because of their potential duration with diabetes.  

Dr. Morton’s primary purpose for the study was to analyze if there was any relationship between the age of onset of type 2 diabetes and the long-term risk of ESKD. The National Diabetes Services Scheme provided data of Australians with diabetes (NDSS). This Australian government-led program is responsible for delivering information and products, at subsidized prices, to patients with diabetes in exchange for collecting limited clinical data. Three years of data such as the date of onset of diabetes, use of insulin, and type of diabetes were recorded and analyzed. Patients with type 2 diabetes were extracted and registered. The initiation of a kidney transplant was a criterion that defined End-Stage Kidney Disease.  Registrants with missing data on the type of diabetes, sex, age, or those who did not receive renal replacement therapy (RRT) were excluded from the study. Next, the date of onset of ESKD was derived from the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA). ANZDATA is a registry for patients that undergo a kidney transplant with or without dialysis. The date of death data was derived by the Australian National Death Index (NDI), where records of all registered deaths are collected. The study registered 1,113,201 people with type 2 diabetes. The average age of onset was 58.1 years.  

Renal transplant surgery is a high-risk operation for most older patients, and the results correlate; 5,671 people died without initiating RRT, and most were in the older categories of the age of onset. The study revealed the benefits of early intervention, and that delaying the onset of type 2 diabetes was an effective method for reducing the risk of ESKD. Furthermore, there was a disproportional relationship with the age of the patient and the risk of developing ESKD. As expected, the incidence of ESKD was higher with increasing duration of diabetes. When ESKD is left untreated, increased age of onset and risk of developing ESKD were proportional, but only for approximately the first 20 years of diabetes; no difference was found afterward.  

“Those diagnosed with diabetes later in life are more likely to die before the onset of ESKD than those diagnosed earlier in life,” Dr. Morton explains, “We observed that in type 2 diabetes, as is the case for type 1 diabetes, diabetes duration is the predominant determinant of ESKD risk. 

Over 385,800 Americans are predicted to die annually by 2050, where diabetes is the underlying cause. Reflecting on Dr. Morton’s Australian study, identifying patients at higher risk for developing prediabetes with a purpose to increase prevention awareness would be more globally beneficial. Dr. Morton’s publication reported a higher incidence of ESKD than the Finland study. Further research focused on discovering direct evidence that links earlier onset of diabetes to a higher risk of ESKD, aside from the duration of the disease, is needed. Hopefully, it will decrease some of the burden and cost that often follows complications of diabetes, while increasing the urgency for preventative awareness.       

Practice Pearls: 

  • End-stage kidney disease is an expensive national burden to Americans.  
  • The earlier the onset of diabetes, the higher the risk of needing a kidney transplant.  
  • Preventing and delaying the onset of type 2 diabetes is a useful tool for reducing the risk of developing end-stage kidney disease. 


Rowley, William. et al. “Diabetes 2030: Insights from Yesterday, Today, and Future Trends.“ Population health management vol. 20,1 (2017): 6-12. doi:10.1089/pop.2015.0181 

Chronic Kidney Disease Basics.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 7 Feb. 2020, www.cdc.gov/kidneydisease/basics.html. 

Morton, J. et al. “The Association Between Age of Onset of Type 2 Diabetes and the Long-term Risk of End-Stage Kidney Disease: A National Registry Study“. Diabetes Care 2020 Aug; 43(8): 1788-1795. 


FinnePatrik. et al. “Cumulative Risk of End-Stage Renal Disease Among Patients with Type 2 Diabetes: A Nationwide Inception Cohort Study” Diabetes Care 2019 Apr; 42(4): 539-544.https://doi.org/10.2337/dc18-1485 


Peter Jay Won, Pharm.D. Candidate, University of South Florida, Taneja College of Pharmacy