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Fig. 3. Adjusted incident rates of end-stage renal disease (ESRD) owing to diabetes by race/ethnicity. Incident ESRD patients; adjusted for age and gender. For Hispanic patients, we present data beginning in 1996, the first full year after the April 1995 introduction of the revised Medical Evidence form, which contains more specific questions on race and ethnicity. The data reported here have been supplied by the US Renal Data System. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government (8).

ethnicity on the prevalence of early DN may be confounded by these factors. For example, no ethnic differences in the prevalence of microalbuminuria were found among newly diagnosed diabetic participants in the UK Prospective Diabetes Study (UKPDS), which included Afro-Caribbean and Asian patients as well as whites (6). Similarly, a US study of patients with variable duration of T2DM found a similar prevalence of microalbuminuria among various ethnic and racial groups (7). However, that same study found the odds of microalbuminuria to be greater among hypertensive Hispanics than among hypertensive whites. Furthermore, among patients without hypertension, the odds of microalbuminuria was highest among Asians.

Transitional and disadvantaged populations are disproportionately represented among patients with diabetic ESRD. In the United States, the US Renal Data System (USRDS) reports that the incidence rate of diabetic ESRD among transitional and dis-advantaged populations is much greater than the rate in the majority white population (Fig. 3) (8). In Europe, several centers have reported disproportionate representation of transitional and minority populations among patients with ESRD (9-11).

In 2004, the USRDS began collecting information, on a voluntary basis, from nations other than the United States (8). Many European countries participated, but specific incidence estimates for transitional or disadvantaged dialysis patients within those countries were not reported. The USRDS also received data from several developing nations. Of these, Malaysia had the highest proportion of diabetic ESRD (Fig. 4). Malaysia has undergone rapid economic transition, and the high incidence of ESRD attributed to DN presumably reflects the growing prevalence of T2DM. In 1984, the prevalence of diabetes was 4% among the residents of three villages in Kuala Selangor province (12). By 1996, the national prevalence of diabetes in Malaysia was 7%— a 75% increase from the estimates in Kuala Selangor province—and an additional 5% of the population had impaired glucose tolerance (13).

Because many studies that examine the epidemiology of DN in T2DM rely on data collected at the time of initiation of dialysis, the quality of epidemiological information is best from developed countries where dialysis is offered. The burden of DN, however, may be greatest in developing countries, where patients with early DN are likely to be underdiagnosed and patients with kidney failure from diabetes are unlikely to receive

Fig. 4. Percent of incident end-stage renal disease (ESRD) patients with diabetes in 2002. Data presented only for those countries from which relevant information was available. All rates are unadjusted. Data from Israel, Japan, Luxembourg, and Taiwan represent dialysis only. The data reported here have been supplied by the US Renal Data System. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government (8).

Fig. 4. Percent of incident end-stage renal disease (ESRD) patients with diabetes in 2002. Data presented only for those countries from which relevant information was available. All rates are unadjusted. Data from Israel, Japan, Luxembourg, and Taiwan represent dialysis only. The data reported here have been supplied by the US Renal Data System. The interpretation and reporting of these data are the responsibility of the author(s) and in no way should be seen as an official policy or interpretation of the US government (8).

dialysis. Under these circumstances, accurate data on the frequency of DN in developing countries are sparse or nonexistent. Nevertheless, data about the frequency of DN and diabetic ESRD are available from some developing countries and from emigrants to the developed countries. These data reflect the different methods and definitions of the authors who report them and different ages of those who were examined. Accordingly, they are neither exhaustive nor definitive, but they reflect the scope of the problem of DN in transitional and disadvantaged populations and they are reviewed next.

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