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)

Jwa-Kyung Kim; Kyung-Do Han; Jun Goo Kang

doi:10.4093/dmj.2025.0593

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Response 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): Jwa-Kyung Kim¹, Kyung-Do Han², Jun Goo Kang¹; Diabetes & Metabolism Journal 2025;49(5):1139-1140.
DOI: https://doi.org/10.4093/dmj.2025.0593
Published online: September 1, 2025

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¹Department of Internal Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, Anyang, Korea

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

Corresponding author: Jun Goo Kang

Division of Endocrinology and Metabolism, Department of Internal Medicine, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, 22 Gwanpyeong-ro 170beon-gil, Dongan-gu, Anyang 14068, Korea E-mail: kjg0804@hallym.or.kr

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 "Burden of End-Stage Kidney Disease by Type 2 Diabetes Mellitus Status in South Korea: A Nationwide Epidemiologic Study" on page 498.

We would like to express our sincere appreciation to Dr. Ji Eun Jun for her thoughtful letter and interest in our article, “Burden of end-stage kidney disease by type 2 diabetes mellitus status in South Korea: a nationwide epidemiologic study,” which was published in the Diabetes & Metabolism Journal [1]. We are pleased that our study, which analyzed data from nearly 4.8 million individuals in the Korean National Health Insurance Service database, has generated meaningful discussion regarding the burden of end-stage kidney disease (ESKD) in relation to diabetes status.

ESKD represents a major national health challenge, not only due to its impact on individual patients but also because of the significant healthcare costs and resource demands it imposes [2]. In this context, understanding population-level trends and risk stratification based on diabetes status is critical for shaping effective prevention and policy strategies.

As noted, earlier studies based on the Korean National Health Insurance Service–National Sample Cohort reported a modest decline in ESKD incidence from 2006 to 2015 [3]. However, more recent and comprehensive international data suggest that the incidence and prevalence of treated ESKD in Korea are still on the rise. According to the 2024 United States Renal Data System Annual Data Report, the Republic of Korea experienced a 63% increase in the incidence of treated ESKD between 2012 and 2022, ranking among the highest globally [4]. During the same period, Korea recorded the third-largest average annual increase in incidence, at 15.7 per million population (pmp) per year, following only Indonesia and Jalisco, Mexico. This trend is particularly notable considering that 17 countries or regions reported a decrease in incidence during the same timeframe. Furthermore, in 2022, Korea ranked second globally in the average annual increase in incidence of ESKD attributed to diabetes, with a rise of 7.3 pmp per year. This highlights the growing contribution of diabetes to Korea’s dialysis burden. In contrast, the United States saw only a 1.8 pmp increase, and several countries reported a decline [4].

These recent figures, based on full-population national surveillance and international benchmarking, strongly support our assertion that the ESKD burden, particularly diabetes-attributed ESKD, continues to rise substantially in South Korea. This reinforces the central message of our study: long-standing diabetes is a critical driver of renal failure in Korea, and national strategies must urgently reflect this continued upward trend.

We agree that improvements in glycemic control and the increasing use of renoprotective agents—including sodium-glucose cotransporter 2 (SGLT2) inhibitors, nonsteroidal mineralocorticoid receptor antagonist, and glucagon-like peptide-1 (GLP-1) receptor agonists in conjunction with renin angiotensin aldosterone system inhibitors—and comprehensive cardiovascular risk management may have attenuated disease progression. However, a significant residual risk for ESKD remains, especially in vulnerable high-risk diabetic populations [5]. Our findings suggest the ongoing need for earlier identification and more aggressive intervention, especially among patients with long-standing diabetes.

In addition, our study notably found that impaired fasting glucose was associated with an increasing tendency for ESKD in younger patients (<65 years) with early-stage chronic kidney disease (≥60 mL/min/1.73 m²). This highlights the importance of early intervention even in prediabetic individuals who might otherwise be considered at lower short-term risk [6]. We concur with your insightful observation that deterioration of kidney function is influenced not only by glycemic thresholds but also by various metabolic pathways of injury, such as inflammation, lipotoxicity, and insulin resistance, which mirror the mechanisms involved in other micro- and macrovascular complications [7,8]. Recent evidence emphasizes the importance of assessing cardiorenal-metabolic (CKM) risk even in younger populations, as early identification of subclinical metabolic dysfunction can offer a crucial window of opportunity for intervention before irreversible organ damage occurs [9]. Tailored CKM evaluation and proactive use of reno- and cardioprotective therapies may help modify disease trajectory in these individuals, reducing long-term morbidity and healthcare burden [10]. This includes not only lifestyle interventions (such as weight management and blood pressure control) but also the early, appropriate use of agents with proven renal benefit, such as GLP-1 receptor agonists and SGLT2 inhibitors, even prior to the development of overt diabetes or advanced nephropathy. These approaches may provide an important opportunity to alter the natural course of diabetic kidney disease, especially in younger populations where long-term disease burden is likely to be substantial.

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CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

REFERENCES

1. Kim JK, Jung HN, Kim BJ, Han B, Huh JH, Roh E, et al. 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.PubMed PMC
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4. Johansen KL, Gilbertson DT, Li S, Li S, Liu J, Roetker NS, et al. US Renal data system 2024 annual data report: epidemiology of kidney disease in the United States. Am J Kidney Dis 2025;85(6S1):A8-11.PubMed
5. Neuen BL, Heerspink HJL, Vart P, Claggett BL, Fletcher RA, Arnott C, et al. Estimated lifetime cardiovascular, kidney, and mortality benefits of combination treatment with SGLT2 inhibitors, GLP-1 receptor agonists, and nonsteroidal MRA compared with conventional care in patients with type 2 diabetes and albuminuria. Circulation 2024;149:450-62.Article PubMed
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7. Narongkiatikhun P, Choi YJ, Hampson H, Gotzamanis J, Zhang G, van Raalte DH, et al. Unraveling diabetic kidney disease: the roles of mitochondrial dysfunction and immunometabolism. Kidney Int Rep 2024;9:3386-402.Article PubMed PMC
8. Ma L, Liu D, Yu Y, Li Z, Wang Q. Immune-mediated renal injury in diabetic kidney disease: from mechanisms to therapy. Front Immunol 2025;16:1587806.Article PubMed PMC
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10. Ndumele CE, Rangaswami J, Chow SL, Neeland IJ, Tuttle KR, Khan SS, et al. Cardiovascular-kidney-metabolic health: a presidential advisory from the American Heart Association. Circulation 2023;148:1606-35.Article PubMed

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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)

Diabetes Metab J. 2025;49(5):1139-1140. Published online September 1, 2025

DOI: https://doi.org/10.4093/dmj.2025.0593

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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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Kim JK, Han KD, Kang JG. 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). Diabetes Metab J. 2025;49(5):1139-1140.

DOI: https://doi.org/10.4093/dmj.2025.0593.

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