Burden of End-Stage Kidney Disease by Type 2 Diabetes Mellitus Status in South Korea: A Nationwide Epidemiologic Study (Diabetes Metab J 2025;49:498-506)
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Type 2 diabetes mellitus (T2DM) is associated with an increased risk of both microvascular and macrovascular complications. End-stage kidney disease (ESKD) in patients with diabetes is a life-threatening complication, resulting in poor prognosis and high medical costs [1]. Patients with ESKD and diabetes have a higher mortality rate than subjects without diabetes [2]. Therefore, when planning and developing healthcare policies, it is important to consider the current status of ESKD, particularly in patients with T2DM.
In the article titled, ‘Burden of end-stage kidney disease by type 2 diabetes mellitus status in South Korea: a nationwide epidemiologic study,’ Kim et al. [3] investigated the risk of developing ESKD relative to diabetes status using a large-scale dataset comprising 4,795,428 participants from the Korean National Health Insurance Service. This large-scale analysis of the South Korean general population suggested that the incidence rate of ESKD was significantly associated with diabetic status, with the highest rates observed in individuals with a diabetes duration of 5 years or more. Furthermore, a reduced estimated glomerular filtration rate (eGFR) was associated with a higher incidence of ESKD compared with individuals with normal eGFR levels. Notably, impaired fasting glucose (IFG) concentration was a significant risk factor for new ESKD and was significantly pronounced in young patients.
Because the global annual incidence of ESKD among patients with diabetes increased from 375.8 to 1,016 per million in 2000–2015 [4], the incidence rate observed in South Korea is substantially higher than reported in other countries. However, the incidence of ESKD decreased slightly in South Korea from 2006 to 2015 despite the increased prevalence of ESKD [5]. The recent decline in ESKD incidence can be attributed to several factors including improved management of diabetic kidney disease such as glycemic control, optimal use of renoprotective drugs such as renin-angiotensin system blockers and sodium-glucose cotransporter 2 inhibitors, nutritional intervention, and intensive management of cardiovascular risk factors [6,7].
Prediabetes, including IFG, is associated with an elevated risk of chronic kidney disease [8]. The deterioration of kidney function is influenced by the glycemic threshold as well as various other metabolic pathways of injury, mirroring the mechanisms involved in other micro- or macrovascular complications [9]. However, the correlation between prediabetes and ESKD, although plausible and rational, has not been fully elucidated. Furthermore, relying solely on IFG levels to diagnose prediabetes might not adequately reflect the association between prediabetes and the risk of ESKD.
Due to the high incidence of ESKD, the authors emphasize the critical nature of diabetic ESKD and highlight the importance of early screening for prediabetes to develop optimal prevention strategies for eGFR decline. However, residual confounding factors might be present due to the inherent limitations of the health insurance claim-related data used in the present study. In addition, eGFR was calculated using the Modification of Diet in Renal Disease formula during health examinations; however, this formula requires further validation in Asian populations [10]. Further large-scale prospective studies are needed to provide more insights into the true nature of ESKD and the association between prediabetes and incident ESKD. In the context of the diabetes pandemic, this approach has potential to aid in screening populations at high risk of ESKD and could help inform individualized prevention strategies.
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CONFLICTS OF INTEREST
No potential conflict of interest relevant to this article was reported.