Association of Systolic and Diastolic Blood Pressure with the Risk of End-Stage Renal Disease in Older Type 2 Diabetes Mellitus Patients without Cardiovascular Disease: A Nationwide Population-Based Study (Diabetes Metab J 2025;49:1308-17)

Sangmo Hong; Kyungdo Han; Kye-Yeung Park; Chang Beom Lee; Dong Sun Kim; Jung Hwan Park; Sung Hoon Yu

doi:10.4093/dmj.2025.1256

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Response Association of Systolic and Diastolic Blood Pressure with the Risk of End-Stage Renal Disease in Older Type 2 Diabetes Mellitus Patients without Cardiovascular Disease: A Nationwide Population-Based Study (Diabetes Metab J 2025;49:1308-17): Sangmo Hong^1*, Kyungdo Han^2*, Kye-Yeung Park³, Chang Beom Lee¹, Dong Sun Kim¹, Jung Hwan Park¹, Sung Hoon Yu¹; Diabetes & Metabolism Journal 2026;50(2):430-431.
DOI: https://doi.org/10.4093/dmj.2025.1256
Published online: March 1, 2026

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¹Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea

²Department of Statistics and Actuarial Science, Soongsil University, Seoul, Korea

³Department of Family Medicine, Hanyang University College of Medicine, Seoul, Korea

Corresponding author: Sung Hoon Yu

Division of Endocrinology and Metabolism, Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, 153 Gyeongchun-ro, Guri 11923, Korea E-mail: physicianyu@daum.net

*Sangmo Hong and Kyungdo Han contributed equally to this study as first authors.

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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See the letter "Association of Systolic and Diastolic Blood Pressure with the Risk of End-Stage Renal Disease in Older Type 2 Diabetes Mellitus Patients without Cardiovascular Disease: A Nationwide Population-Based Study (Diabetes Metab J 2025;49:1308-17)" on page 416.

We sincerely appreciate the thoughtful and constructive comments from Wang and Shao regarding our recently published article [1]. Their insights regarding the proportional hazards (PH) assumption and the treatment of competing risks provide an important opportunity to further clarify and strengthen the methodological rigor of our analysis. Below, we address each concern in detail.

We fully agree with the authors on the importance of the PH assumption in Cox regression models. Although we did not explicitly detail the diagnostic procedures in the final manuscript for the sake of brevity, we did assess the PH assumption during our preliminary analysis. We utilized both log-minus-log plots and Schoenfeld residuals to check for any violation of the assumption. Our diagnostic checks did not reveal substantial deviations that would invalidate the reported estimates. We apologize for the omission of these details in the published text and appreciate the authors pointing out the need for this transparency.

The authors correctly pointed out that in an elderly population with type 2 diabetes mellitus, death acts as a significant competing risk for end-stage renal disease (ESRD). We acknowledge that standard Kaplan-Meier estimates may overestimate the cumulative incidence of the event of interest in the presence of competing risks.

However, as discussed in previous literature [2,3], there is a distinct difference in the interpretation and utility of the standard Cox model and the Fine-Gray model. The cause-specific hazard model (standard Cox) is generally preferred for addressing etiological questions, as it estimates the instantaneous rate of event occurrence among subjects who are currently event-free [2,4]. In contrast, the Fine-Gray model (subdistribution hazard) is better suited for estimating absolute risk and clinical prognosis [2]. Since our study aimed to investigate the direct biological association between blood pressure components and the development of ESRD rather than to build a predictive model for absolute risk, we believe the cause-specific hazard approach remains methodologically valid for our research question.

Unfortunately, conducting a post hoc analysis using the Fine-Gray model is not feasible at this stage due to data access limitations. Nevertheless, we fully accept the authors’ constructive suggestion as a limitation of our study. Future research involving this high-risk geriatric population should certainly incorporate competing risk analyses to provide a more comprehensive perspective on absolute risk.

We hope this response adequately addresses the concerns raised and clarifies our methodological stance.

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CONFLICTS OF INTEREST

Sung Hoon Yu has been an associate editor of the Diabetes & Metabolism Journal since 2022. He was not involved in the review process of this article. Otherwise, there was no conflict of interest.

ACKNOWLEDGMENTS

The National Health Information Database is maintained by the National Health Insurance Service of Korea. The authors would like to thank the National Health Insurance Service for their cooperation.

REFERENCES

1. Hong S, Han K, Park KY, Lee CB, Kim DS, Park JH, et al. Association of systolic and diastolic blood pressure with the risk of end-stage renal disease in older type 2 diabetes mellitus patients without cardiovascular disease: a nationwide population-based study. Diabetes Metab J 2025;49:1308-17.Article PubMed PMC PDF
2. Austin PC, Lee DS, Fine JP. Introduction to the analysis of survival data in the presence of competing risks. Circulation 2016;133:601-9.Article PubMed PMC
3. Lau B, Cole SR, Gange SJ. Competing risk regression models for epidemiologic data. Am J Epidemiol 2009;170:244-56.Article PubMed PMC
4. Dignam JJ, Zhang Q, Kocherginsky M. The use and interpretation of competing risks regression models. Clin Cancer Res 2012;18:2301-8.Article PubMed PMC PDF

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Association of Systolic and Diastolic Blood Pressure with the Risk of End-Stage Renal Disease in Older Type 2 Diabetes Mellitus Patients without Cardiovascular Disease: A Nationwide Population-Based Study (Diabetes Metab J 2025;49:1308-17)

Diabetes Metab J. 2026;50(2):430-431. Published online March 1, 2026

DOI: https://doi.org/10.4093/dmj.2025.1256

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Hong S, Han K, Park KY, Lee CB, Kim DS, Park JH, Yu SH. Association of Systolic and Diastolic Blood Pressure with the Risk of End-Stage Renal Disease in Older Type 2 Diabetes Mellitus Patients without Cardiovascular Disease: A Nationwide Population-Based Study (Diabetes Metab J 2025;49:1308-17). Diabetes Metab J. 2026;50(2):430-431.

DOI: https://doi.org/10.4093/dmj.2025.1256.

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