Correspondence
n engl j med  375;  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 predomi-nant cause in developing countries.1 We hypothe-sized that the surging prevalence of diabetes in developing countries may have a substantial ef-fect 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 hospital-ized persons and another that tracks the general population in China. To track hospitalized per-
sons, we used the Hospital Quality Monitoring System, a mandatory patient-level national data-
base for hospital accreditation, under the author-ity 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 simi-lar to tertiary hospitals but also provide primary of Diseases and Related Health Problems, 10th Revision,were used to extract cases of chronic kidney dis-ease related to diabetes and to glomerulonephri-to glomerulonephritis according to the patients’ medical history and laboratory test results.
In 2010, among hospitalized patients, the per-centage with chronic kidney disease related to diabetes was lower than the percentage with chronic kidney disease related to glomerulone-phritis (0.82% vs. 1.01%). Starting from 2011, the percentage with chronic kidney disease re-lated to diabetes exceeded the percentage with chronic kidney disease related to glomerulone-phritis, 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 glomerulone-phritis was 1.10% and 0.75%, respectively. In both 2010 and 2015, the percentage of hospital-Figure 1. Trends in Chronic Kidney Disease Related to Diabetes and to Glomerulonephritis among Hospitalized
P atients 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
0.710.87
0.97
1.01
1.10
1.01
0.66
0.69
0.80
0.73
0.75
H o s p i t a l i z e d  P a t i e n t s  w i t h  D i a b e t e s  M e l l i t u s a n d  C h r o n i c  K i d n e y  D i s e a s e  (%)
H o s p i t a l i z e d  P a t i e n t s  w i t h  C h r o n i c  K i d n e y D i s e a s e  R e l a t e d  t o  D i a b e t e s  M e l l i t u s  a n d t o  G l o m e r u l o n e p h r i t i s  (%)
12
810
6420
1.21.00.60.80.40.2
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
editor evaluating revision8,948,853
14,126,414
11,175,678
The New England Journal of Medicine
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Correspondence
n engl j med  375;  September 1, 2016
906
ized urban patients with chronic kidney disease related to diabetes was higher than that of hos-pitalized 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 percent-age with chronic kidney disease related to diabe-tes 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 per-centage 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 inter-val [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 pa-tients with chronic kidney disease related to dia-betes in China was 24.3 million, of whom 60.5% have preserved kidney function with slightly in-creased albuminuria.
Our study indicates that chronic kidney dis-ease related to diabetes has become more com-mon than chronic kidney disease related to glomerulonephritis in both the general popula-tion and a hospitalized urban population in China, a finding that is preceded by decades of increasing prevalence of diabetes mellitus.3,4Luxia 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 Refer-ence 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 R
epub-lic of China (the National Key Technology R&D Program, 2011BAI10B01), the Beijing Science and Technology Committee (Establishment of Early Diagnosis Pathway and Model for Evaluat-ing 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
1. B arsoum 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 on September 12, 2016. For personal use only. No other uses without permission.
Copyright © 2016 Massachusetts Medical Society. All rights reserved.

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