CORRESPONDENCE Trends in Chronic Kidney Disease in China TO THE EDITOR: Diabetes is the leading cause of Diseases and Related Health Problems, 10th Revision of end-stage kidney disease worldwide, though were used to extract cases of chronic kidney dis- glomerulonephritis has been the more predomi- ease related to diabetes and to glomerulonephri developing countries. We hypothe- tis. To track the general population in China, ized that the surging prevalence of diabetes in used a general population-based, nationally rep- developing countries may have a substantial ef- resentative sample of 47, 204 participants from fect on the observed spectrum of chronic kidney 2009 through 2010. We classified chronic kidney disease disease as being related to diabetes mellitus or related to diabetes or to glomerulonephritis, we medical history and laboratory test resuls nts To evaluate trends in chronic kidney disease to glomerulonephritis according to the patie sed two resources -one that tracks hospital- In 2010, among hospitalized patients, the per- ized persons and another that tracks the general centage with chronic kidney disease related to population in China. To track hospitalized per- diabetes was lower than the percentage with sons, we used the Hospital Quality Monitoring chronic kidney disease related to glomerulone- System, a mandatory patient-level national data- phritis (0.82% vs. 1.01%). Starting from 2011, base for hospital accreditation, under the author- the percentage with chronic kidney disease re- ity of the National Health and Family planning lated to diabetes exceeded the percentage with Commission of the People,'s Republic of China. chronic kidney disease related to glomerulone We analyzed a data set of 35.3 million patients phritis, and the gap between them increased hospitalized in class 3 hospitals(which are simi- progressively(Fig. 1). In 2015, the percentage of lar to tertiary hospitals but also provide primary the hospitalized population with chronic kidney and secondary care to the nationwide patient disease related to diabetes and to glomerulone- population) from 2010 through 2015. Diagnosis phritis was 1.10% and 0.75%, respectively. In codes from the International Statistical Classification both 2010 and 2015, the percentage of hospital Chronic kidney disease related to diabetes mellitus 1.10[1.2 0.87 Chronic kidney disease related Diabetes mellitus Chronic kidney disease 2012 2013 No at risk 165.771 252,240 894885314,126,41411,175,678 Figure 1. Trends in Chronic Kidney Disease Related to Diabetes and to Glomerulonephriti Hospitalized Patients in China The percentages shown were calculated among overall hospitalized patients in each year. numbers of hospitalized patients for each year(numbers at risk were obtained from the Hospital Qu itoring System, which is a mandatory patient-level national database for hospital accreditation, under the of Nation Health and Family Planning Commission of the People's Republic of China N ENGL J MED 375:9 NEJM. ORG SEPTEMBER 1, 2016 90 England Journal of medicin Downloaded from nejm. org at PEKING UNIVERSITY on May 19, 2019. For personal use only. No other uses without perr Copyright o 2016 Massachusetts Medical Society. All rights reserved
Correspondence n engl j med 375;9 nejm.org September 1, 2016 905 Trends in Chronic Kidney Disease in China To the Editor: Diabetes is the leading cause of end-stage kidney disease worldwide, though glomerulonephritis has been the more predominant cause in developing countries.1 We hypothesized that the surging prevalence of diabetes in developing countries may have a substantial effect on the observed spectrum of chronic kidney disease. To evaluate trends in chronic kidney disease related to diabetes or to glomerulonephritis, we used two resources — one that tracks hospitalized persons and another that tracks the general population in China. To track hospitalized persons, we used the Hospital Quality Monitoring System, a mandatory patient-level national database for hospital accreditation, under the authority of the National Health and Family Planning Commission of the People’s Republic of China. We analyzed a data set of 35.3 million patients hospitalized in class 3 hospitals (which are similar to tertiary hospitals but also provide primary and secondary care to the nationwide patient population) from 2010 through 2015. Diagnosis codes from the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, were used to extract cases of chronic kidney disease related to diabetes and to glomerulonephritis. To track the general population in China, we used a general population-based, nationally representative sample of 47,204 participants from 2009 through 2010. We classified chronic kidney disease as being related to diabetes mellitus or to glomerulonephritis according to the patients’ medical history and laboratory test results. In 2010, among hospitalized patients, the percentage with chronic kidney disease related to diabetes was lower than the percentage with chronic kidney disease related to glomerulonephritis (0.82% vs. 1.01%). Starting from 2011, the percentage with chronic kidney disease related to diabetes exceeded the percentage with chronic kidney disease related to glomerulonephritis, and the gap between them increased progressively (Fig. 1). In 2015, the percentage of the hospitalized population with chronic kidney disease related to diabetes and to glomerulonephritis was 1.10% and 0.75%, respectively. In both 2010 and 2015, the percentage of hospitalFigure 1. Trends in Chronic Kidney Disease Related to Diabetes and to Glomerulonephritis among Hospitalized Patients in China. The percentages shown were calculated among overall hospitalized patients in each year. The overall numbers of hospitalized patients for each year (numbers at risk) were obtained from the Hospital Quality Monitoring System, which is a mandatory patient-level national database for hospital accreditation, under the authority of National Health and Family Planning Commission of the People’s Republic of China. 0.82 0.71 0.87 0.97 1.01 1.10 1.01 0.66 0.69 0.80 0.73 0.75 Hospitalized Patients with Diabetes Mellitus and Chronic Kidney Disease (%) Hospitalized Patients with Chronic Kidney Disease Related to Diabetes Mellitus and to Glomerulonephritis (%) 12 8 10 6 4 2 0 1.2 1.0 0.6 0.8 0.4 0.2 0.0 2010 2011 2012 2013 2014 2015 Chronic kidney disease related to diabetes mellitus Chronic kidney disease related to glomerulonephritis Diabetes mellitus Chronic kidney disease No. at Risk 596,857 165,771 252,240 8,948,853 14,126,414 11,175,678 The New England Journal of Medicine Downloaded from nejm.org at PEKING UNIVERSITY on May 19, 2019. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved
CORRESPONDENCE ized urban patients with chronic kidney disease Jianyan Long, M.Sc. related to diabetes was higher than that of hos- Wenshi Jiang, M.Sc. pitalized urban patients with chronic kidney Ying Shi, B M.S disease related to glomerulonephritis, and the gap Xiangxiang He, M S had increased by 2015(1.02% vs 0.84% in 2010 Zhiye Zhou, MS and 1.55% vs. 0.72% in 2015). However, among Yanwei Li, BSc hospitalized rural patients during that same China Standard Medical Information Research Center time frame, glomerulonephritis-related chronic Shenzhen,China kidney disease predominated, and the percent. Roseanne O Yeung, M.D., M.P.H tes was lower than the percentage with chronic Hong Kong, Chief Hong Kong age with chronic kidney disease related to diabe- Chinese University ley disease related to gl omerwlone phritis, Jinwei Wang, Ph.D though the gap had narrowed by 2015(0.68% vS. Peking University First Hospital 151%in2010,and0.76%vs.0.95%in2015). el]ing. In the general population, the percentage with Kunihiro Matsushita, M.D., PhD nronic kidney disease related to diabetes also Josef Coresh, M D, Ph D exceeded the percentage with chronic kidney Johns Hopkins Bloomberg School of Public Health disease related to glomerulonephritis (1.23% vs. Baltimore, MD 0.91%) When stratified according to the area of Ming-Hui Zhao, M.D. residence, the percentage with chronic kidney Peking University First Hospital disease related to diabetes surpassed the per- Beijing. China centage with chronic kidney disease related to Haibo Wang, M.B.,BS, M.P.H glomerulonephritis among both urban and rural First Affiliated Hospital of Sun Yat-Sen University residents, though the gap was narrower among haibo(mail.harvard.edu rural residents.76%(95% confidence inter- Drs Zhang and H, Wang contrib ed equation (WHo refer. 0.96)among urban residents, and 1.32%(95% ence 20141435380-0 and 2015/533939-0 for the China-World Cl,117 to 1. 47)vS. 0.89(95% Cl, 0.77 to 1.02%o) the Ministry of Science and Technology of the people's Repub. among rural residents. Approximately 21. 3% of lic of China (the National Key Technology R&D Program, the participants with diabetes were classified as 2011BAl10B01), the Bejing Science and Technology Committe having chronic kidney disease in our study. (Establishment of Early Diag Pathway and Model for Evaluar ing Progression of Chronic Kidney Disease, D131100004713007) Hence, on the basis of a study in 2013 that and the National Health and Family planning Commission of showed there were 113.9 million persons with the people's Republic of China diabetes in China, 2 the estimated number of pa- Disclosure forms provided by the authors are available with tients with chronic kidney disease related to dia the full text of this letter at NEJM.org. betes in China was 24.3 million, of whom 60.5%% 1. Barsoum RS. Chronic kidney disease in the developing have preserved kidney function with slightly in- 2. Xu y, wang l, 06:354..9 et al. Prevalence and control of diabetes creased albuminuria in Chinese adults. JAMA 2013: 310: 948-59 Our study indicates that chronic kidney dis- 3. Yang w, Lu 1, Weng ), et al Prevalence of diabetes among ase related to diabetes has become more com- men and women in China. N Engl)Med 2010: 362: 1090-101 mon than chronic kidney disease related to and its risk factors in Chin a,1994. Diabetes Care 1997: 20 glomerulonephritis in both the general popula- 1664-9 tion and a hospitalized urban population in Dol: 10.1056/NEJMc1602469 China, a finding that is preceded by decades of Correspondence Copyright o 2016 Massachusetts Medical Society increasing prevalence of diabetes mellitus. 4 Zhang, M.D., M.P.H University First Hospital N ENGL J MED 375:9 NEJM.ORG SEPTEMBER 1, 2016 England Journal of medicin Downloaded from nejm. org at PEKING UNIVERSITY on May 19, 2019. For personal use only. No other uses without perr Copyright o 2016 Massachusetts Medical Society. All rights reserved
Correspondence 906 n engl j med 375;9 nejm.org September 1, 2016 ized urban patients with chronic kidney disease related to diabetes was higher than that of hospitalized urban patients with chronic kidney disease related to glomerulonephritis, and the gap had increased by 2015 (1.02% vs. 0.84% in 2010 and 1.55% vs. 0.72% in 2015). However, among hospitalized rural patients during that same time frame, glomerulonephritis-related chronic kidney disease predominated, and the percentage with chronic kidney disease related to diabetes was lower than the percentage with chronic kidney disease related to glomerulonephritis, though the gap had narrowed by 2015 (0.68% vs. 1.51% in 2010, and 0.76% vs. 0.95% in 2015). In the general population, the percentage with chronic kidney disease related to diabetes also exceeded the percentage with chronic kidney disease related to glomerulonephritis (1.23% vs. 0.91%). When stratified according to the area of residence, the percentage with chronic kidney disease related to diabetes surpassed the percentage with chronic kidney disease related to glomerulonephritis among both urban and rural residents, though the gap was narrower among rural residents — 1.76% (95% confidence interval [CI], 1.61 to 1.93) vs. 0.84% (95% CI, 0.73 to 0.96) among urban residents, and 1.32% (95% CI, 1.17 to 1.47) vs. 0.89 (95% CI, 0.77 to 1.02%) among rural residents. Approximately 21.3% of the participants with diabetes were classified as having chronic kidney disease in our study. Hence, on the basis of a study in 2013 that showed there were 113.9 million persons with diabetes in China,2 the estimated number of patients with chronic kidney disease related to diabetes in China was 24.3 million, of whom 60.5% have preserved kidney function with slightly increased albuminuria. Our study indicates that chronic kidney disease related to diabetes has become more common than chronic kidney disease related to glomerulonephritis in both the general population and a hospitalized urban population in China, a finding that is preceded by decades of increasing prevalence of diabetes mellitus.3,4 Luxia Zhang, M.D., M.P.H. Peking University First Hospital Beijing, China Jianyan Long, M.Sc. Wenshi Jiang, M.Sc. Ying Shi, B.M.S. Xiangxiang He, M.Sc. Zhiye Zhou, M.S. Yanwei Li, B.Sc. China Standard Medical Information Research Center Shenzhen, China Roseanne O. Yeung, M.D., M.P.H. Chinese University of Hong Kong Hong Kong, China Jinwei Wang, Ph.D. Peking University First Hospital Beijing, China Kunihiro Matsushita, M.D., Ph.D. Josef Coresh, M.D., Ph.D. Johns Hopkins Bloomberg School of Public Health Baltimore, MD Ming-Hui Zhao, M.D. Peking University First Hospital Beijing, China Haibo Wang, M.B., B.S., M.P.H. First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China haibo@mail.harvard.edu Drs. Zhang and H. Wang contributed equally to this letter. Supported by the World Health Organization (WHO Reference 2014/435380-0 and 2015/533939-0 for the China–World Health Organization Biennial Collaborative Projects 2014–2015), the Ministry of Science and Technology of the People’s Republic of China (the National Key Technology R&D Program, 2011BAI10B01), the Beijing Science and Technology Committee (Establishment of Early Diagnosis Pathway and Model for Evaluating Progression of Chronic Kidney Disease, D131100004713007), and the National Health and Family Planning Commission of the People’s Republic of China. Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org. 1. Barsoum RS. Chronic kidney disease in the developing world. N Engl J Med 2006;354:997-9. 2. Xu Y, Wang L, He J, et al. Prevalence and control of diabetes in Chinese adults. JAMA 2013;310:948-59. 3. Yang W, Lu J, Weng J, et al. Prevalence of diabetes among men and women in China. N Engl J Med 2010;362:1090-101. 4. Pan XR, Yang WY, Li GW, Liu J. Prevalence of diabetes and its risk factors in China, 1994. Diabetes Care 1997;20: 1664-9. DOI: 10.1056/NEJMc1602469 Correspondence Copyright © 2016 Massachusetts Medical Society. The New England Journal of Medicine Downloaded from nejm.org at PEKING UNIVERSITY on May 19, 2019. For personal use only. No other uses without permission. Copyright © 2016 Massachusetts Medical Society. All rights reserved