Diabetic nephropathy as the cause of end-stage kidney disease reported on the medical evidence form CMS2728 at a single center

Abstract

Background: End-stage renal disease (ESRD) incidence due to Type 2 diabetic nephropathy (DN) is 35–50%, according to the United States Renal Data System. Methods: A single-center, retrospective cohort study to determine incidence and diagnostic accuracy for Type 2 DN as the primary cause of ESRD (Code 250.40) on the Center for Medicare & Medicaid (CMS) Medical Evidence Report form (CMS2728) submitted at renal replacement therapy initiation. All patients ≥18 years of age with a CMS2728 submitted between 1 March 2006 and 31 March 2015 at a single academic military medical center (ESRD Network 5) were included. Medical records of those with a Code 250.40 diagnosis were reviewed to determine whether they met the Kidney Disease Outcomes Quality Initiative (KDOQI) 2007 criteria for DN. Results: ESRD incidence secondary to Type 2 DN was 18.7% (56/299 individual CMS2728 submissions over 9.09 years). In all, 12/56 (21.4%) did not meet KDOQI criteria for Type 2 DN. Although all had diabetes, those not meeting criteria had shorter disease duration (P = 0.007), were more likely to have active urine sediment (P = 0.006), and were less likely to have macroalbuminuria (P = 0.037) or retinopathy (P = 0.002) prior to ESRD. On exact logistic regression, retinopathy was significantly associated with KDOQI-predicted DN [odds ratio = 19.16 (confidence interval 2.76–223.7), P = 0.0009]. Conclusions: In this single-center cohort, 21.4% identified as having Type 2 DN as the primary cause of ESRD were incorrectly assigned per KDOQI 2007 clinical criteria. If replicated in larger populations, this could have substantial implications regarding the epidemiology of ESRD in the USA.

Need to Reclassify Etiologies of ESRD on the CMS 2728 Medical Evidence Report

“…Patients with diabetes and advancing nephropathy are frequently labeled with diabetic kidney disease (DKD), despite awareness that they may have diabetes coincident with another etiology of kidney disease (10). Many patients with progressive DKD manifest heavy proteinuria, whereas others have early declines in eGFR without proteinuria.…”

“…In individuals whose diabetes developed before nephropathy, it would be helpful to include diabetes duration before ESRD in Section 17 ("Co-Morbid Conditions") of the 2728 form. Shorter diabetes durations before onset of ESRD and lack of nonrenal microvascular complications (included in Section 17) suggest higher likelihoods of nondiabetes-associated ESRD (10).…”

Diabetic Nephropathy an Obvious Complication in Long Term Type 1 Diabetes Mellitus: A Case Study

“…FGF23 inhibits 1-a hydroxylase gene with consequent decreased calcitriol synthesis. The previous study shown an inverse relationship between calcitriol and renin levels [29,30].…”

The large spectrum of renal disease in diabetic patients

“…In this issue of CKJ , Yuan et al addressed the accuracy of a clinical diagnosis of DN among diabetic patients following the criteria proposed by the KDOQI guidelines [6]. Around 20% of patients did not meet KDOQI criteria for DN in type 2 DM, suggesting a significant overestimation of DN in this population.…”

“…They showed that those patients lacking KDOQI-predicted DN were more likely to have an active urine sediment and less likely to have developed macroalbuminuria or retinopathy prior to end-stage renal disease. Using the binary logistic regression analysis, diabetic retinopathy was the only factor independently associated with patients who met KDOQI criteria [6]. …”