Chronic Kidney Disease Increasingly Driven By Diabetes

The prevalence of chronic kidney disease (CKD) in the U.S. was generally stable over the past decade, but the underlying diagnoses driving the condition changed over time, according to National Health and Nutrition Examination Survey data.

During the 2013-2014 survey cycle, 14.5% of U.S. adults had CKD. That figure crept up slightly to 14.8% during the 2021-2023 cycle, corresponding to an estimated 36 million adults, reported Ashish Verma, MBBS, and Sophie Claudel, MD, both of the Boston University Chobanian & Avedisian School of Medicine, in the New England Journal of Medicine.

“This is the first CKD study to utilize recently released survey data spanning a decade, encompassing the period during which the first therapies specifically approved to protect the kidneys … were introduced into the market,” Verma said in a statement, pointing to SGLT2 inhibitors and the nonsteroidal mineralocorticoid receptor antagonist finerenone (Kerendia).

“Remarkably, despite these advancements, overall CKD rates have remained stagnant,” he pointed out.

In fact, instead of improving, CKD due to diabetes increased from 4.7% to 5.7% during this timeframe. Diabetes was the coexisting condition carrying the highest adjusted prevalence ratio at 2.49, meaning it was substantially more common in people with CKD than those without. Conversely, there was no change in the prevalence of CKD among individuals without diabetes.

Heart failure also was strongly linked with prevalent CKD throughout the study period, peaking during the 2021-2023 cycle with an adjusted prevalence ratio of 2.47, trailing just behind diabetes.

This means single-organ care is no longer enough, said Claudel. Based on the data, a growing proportion of the population may be at risk for progressive cardiovascular-kidney-metabolic (CKM) syndrome.

“What we’re seeing is that kidney disease no longer travels alone,” she explained. “About one in four Americans with heart disease also has CKD, and the links between kidney disease, heart failure, and diabetes are getting stronger, not weaker.”

Verma called the mounting link between diabetes and CKD a “concerning trend,” emphasizing the critical demand for new research and targeted interventions to manage this growing health burden.

Indeed, the authors noted that blood pressure control, glycemic control, and the appropriate prescription of kidney-protective medications remained “stagnant and suboptimal throughout the study period.”

Moreover, there may be an urgent need to better screen for CKD; according to CDC data, roughly 87% of adults with CKD were unaware they had it.

Albuminuria testing holds immense promise as a tool for identifying early kidney disease, Verma and Claudel suggested. “Efforts to appropriately screen for CKD among persons with diabetes, hypertension, or cardiovascular disease and equitably implement newer kidney-protective therapies may shift the population-level prevalence of CKD,” they wrote.

In the meantime, the economic and public health impacts of CKD remain severe. The condition accounts for $141 billion in Medicare fee-for-service spending annually in the U.S. As of 2023, CKD entered the top 10 causes of death worldwide, accounting for an estimated 1.48 million global deaths, and was ranked as the 12th leading cause of lost disability-adjusted life-years.

Verma and Claudel analyzed data from 25,106 adults, ages 20 and older, who participated in four National Health and Nutrition Examination Survey cycles. CKD was defined as an eGFR of less than 60 mL/min/1.73 m² or a urinary albumin-to-creatinine ratio of 30 mg/g or more. Prevalence estimates were age-standardized to the 2020 U.S. Census.

Throughout the study period, more adults met the criteria for CKD based on albuminuria alone than on a low eGFR alone (8.6% vs 4.1%).

The researchers found that prevalence varied widely by demographic and socioeconomic factors, with higher rates observed among Black adults and those living below the federal poverty threshold. Educational disparities in CKD prevalence also were steep.