Chronic renal diseases as a public health problem

1
Chronic renal diseases as a public health problem

• Epidemiology, Social and Economical Implications

Arrigo Schieppati Bellagio March 16, 2004
2
The Global Burden of Disease and
Injury Researchers at the Harvard School of
Public health and WHO have produced a
comprehensive set of estimates of current pattern
of mortality and disability for all regions of
the world
http//www3.who.int/whosis/menu.cfm?pathevidence,
burdenlanguageenglish
3

• According to the GBD estimates for the year 2002,
  chronic kidney diseases ranked
• 12th as a cause of Death
• 17th as a cause of Disability Adjusted Life
  Years (DALYs)

http//www3.who.int/whosis/menu.cfm?pathevidence,
burdenlanguageenglish
4
GLOBAL BURDEN OF DISEASE ANNUAL DEATHS
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GLOBAL BURDEN OF DISEASE DALYs
6
Regional distribution of Genito-urinary diseases
WHO Region GU deaths of all of
deaths deaths due to all NCD Africa 105,338
0.98 21 America 135,765 2.20 76 East
Mediterran 82,571 1.98 49 Europe 112,085 1.1
8 85 South East Asia 206,136 1.41 50 West
Pacific 202,712 1.70 75
http//www3.who.int/whosis/menu.cfm?pathevidence,
burdenlanguageenglish
7

• In the Global Burden of Disease report, renal
  diseases are grouped under the item Disease of
  the Genitourinary System, which is articulated
  into two categories
• Nephrosis and nephritis
• Benign prostatic hypertrophy
• too generic terms for allowing full appreciation
  of the global burden of chronic kidney diseases

8
Other sources of Information

• Renal Registries are the most valuable source of
  information on ESRD demographics, treatment
  practices, and outcome
• They also provide a base for international
  comparisons and aid understanding practice and
  policies variation in different part of the world

9
However...

• Data collection and analysis requires extensive
  resources and often timely reporting is difficult
  
• Information on ESRD from developing countries is
  even more difficult and often relies on personal
  account of leading nephrologists or sporadic
  publications

10
Renal Registries on the Internet

• http//www.ifrr.net/
• http//www.usrds.org/
• http//www.era-edta-reg.org/index.jsp
• http//www.unifesp.br/dis/gamba/rgbrinti.htm
• http//www.renalreg.com/
• http//www.quasi-niere.de/
• http//www.sin-ridt.org/sin-ridt/sin-ridt.org.htm
• http//www.nephro.at/
• http//www.nbvn.be/
• http//www.dns.suite.dk/dns.htm
• http//www.renine.nl/

• International
• USA
• Europe
• Brazil
• UK
• Germany
• Italy
• Austria
• Belgium
• Denmark
• The Netherlands

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• In 2001 Fresenius Medical Care dialysis network
  carried out a global survey on RRT worldwide
• Data were collected through survey forms based on
  a catalogue of 12 items relevant to the treatment
  of ESRD

Moeller et al. NDT 2002
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Countries surveyd 120 Population 5.7 billion
(90 world pop)
Moeller et al. NDT 2002
13
People on RRT in 2001

• 1 479 000

Moeller et al. NDT 2002
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Treatment modalities
TX
PD
HD
Moeller et al. NDT 2002
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Regional ESRD distribution
Region Pop. GDP ESRD million US
(000) Prevalence pmp EU 380 21.7
790 Europe 804 12.0 393 M. East
271 3.2 150 Africa 833 1.0
55 L.America 512 3.8 310 Asia
3316 1.1 55 Japan 127
37.6 1830 N.America 310 29.5 1400
Moeller et al. NDT 2002
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Country Pop. of world Dialysis of
dialysis (million) pop. pop.(x000)
pop USA 279 4.5 288
25 Japan 127 2.1 220
19 Germany 83 1.3 54 5
Brazil 175 2.8 54 5 Italy
58 0.9 42 4 615a 1785
28.8 243 21 16120a 3179 51.4
240 21 121232a 503 8.1 0
0
Moeller et al. NDT 2002
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• 58 of dialysis population is treated in 5
  countries with less than 12 of world population
• The next 10 countries, ranked by size of dialysis
  population, accounted for 21 of global dialysis
  patients and represent 29 of world population
• Japan, USA, Germany, Brazil, Italy

Moeller et al. NDT 2002
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RRT in Latin America
COUNTRY ESRD Tot pop pmp Argentina
271 33.4 m Bolivia 16 7.9 m Brazil
162 159 m Chile 215 13.8
m Colombia 38 34.8 m Ecuador 31.2 11.3
m Mexico 140 94.2 m Uruguay 498 3.1
m Venezuela 130 21.2m
Mazzucchi et al. NDT 1997
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RRT in Asia
COUNTRY ESRD Tot pop pmp Thailand
96 62 m Philippines 35 72
m Malaysia 262 23 m Brunei 1077 0.3
m Korea 584 48
m Taiwan 1359 22 m Japan 1623 127m Cambo
dia 4 11 m Vietnam 5 78
m Singapore 716 3 m Myanmar
3 51 m
Sitprija, Kidney Int 2003
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RRT in Asia

• The Asian-Pacific Region (1998-2000)
• 1.684.220.000 population

ESRD patients
1998
change
2000
4,401 851 5,139 5,977 26,039 28,683 195,756 1,229
5,964 2,486 6,028 6,341 28,044 29,888 206,131 1,32
5
35,5 19,2 17,3 6,1 7,7 4,2 5,3 7,8
Thailand Philippines Malaysia Australia Korea Taiw
an Japan New Zealand
Lee, Semin Nephrol, 2003
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RRT in North Africa
COUNTRY ESRD Tot pop pmp Algeria 3
4 30.4 m Egypt 264 63.8 m Libya 30 5.5
m Tunisia 430 9.6 m Morocco 52 28.7 m
Barsoum, Kidney Int, 2003
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RRT in Sub-Saharan Africa
COUNTRY DIALYSIS POP. GEN.POP S.Africa 22
00 43 m Nigeria 300 120
m Kenya 220 29 m Cote dIvoire
130 15.5 m Mauritania 50 2.5
m Ghana 30 20 m Cameroon
30 15.5 m Senegal 25 10
m Ethiopia 5 75 m
Bamgboye, Kidney Int, 2003
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Use of PD as RRT modality
Source USRDS 2003
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Transplant rates
Source USRDS 2003
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Causes of ESRD in incident patients
GN DN HT RVD PKD PN Europe 7-20 15-33 4-24
0-13 5-11 5-10 Latin America 8-35 11-51
11-22 1-6.5 3.9-7.5 Australia 26 26
16 6 4 USA 9 44 27 2 2
EDTA registry includes Spain, UK,
Belgium,Denmark, Sweeden, Austria. Greece,
Norway, Netherlands, Finland
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Incident patients with Diabetes
Source USRDS 2003
27

• In INDIA approximately 100,000 pts develop ESRD
  every year
• 10 consult nephrologist
• 9000 start RRT
• 60 of them stop within 3 months
• 17-23 of those still on dialysis after 2 months
  receive transplantation

Kher, Kidney Int, 2002
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FIRST YEAR OUTCOME OF RRT IN INDIA
Kher, Kidney Int, 2002
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• The number of patients treated for end-stage
  renal disease (ESRD) has demonstrated continous
  growth since the establishment of dialysis and
  transplantation as life-sustaining therapies

30

• The growth of the number of ESRD patients is 5
  times greater than the world population growth
  (1.3)
• There is no sign that the growth has reached a
  steady state in the next 20 years

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GLOBAL MAINTENANCE DIALYSIS POPULATION FROM 1990
TO 2010
2,500,000
1,490,000
426,000
1990
2010
2000
Lysaght, J Am Soc Nephrol, 2002
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PREVALENCE OF ESRD IN THE DEVELOPED COUNTRIES IS
RAPIDLY INCREASING
1997
2001
2000
America
Europe
Asia/Oceania
1642
1500
1403
1397
Prevalence of ESRD (patients/pmp)
1000
1131
920
841
788
690
683
650
633
500
530
0
USA
Canada
Germany
Italy
Japan
Australia
USRDS, Report 2003
33

• The reasons of this growth are
• Global ageing
• Multi-morbid population
• Higher life-expectancy of ESRD patients
• Increasing access of younger people in countries
  in which RRT has been limited until today

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WHY THE BURDEN OF CHRONIC KIDNEY DISEASE IS
GROWING ?
The shift from an active life as farmers to a
less-active lifestyle associated with
urbanization, and the increased consumption of
sugar and fat, are among the factors responsible
for the rise of obesity and related diseases,
such as diabetes
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PROJECTED CHANGES OF ISCHEMIC HEART DISEASE
MORTALITY WORLDWIDE
(1990 to 2020)
5000
DEVELOPING COUNTRIES
Deaths (x 1000)
4000
3000
DEVELOPED COUNTRIES
2000
1000
0
1990
2020
Yusuf et al., Circulation, 2001
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RENAL DISEASES ARE INDEPENDENT RISK FACTORS FOR
CARDIOVASCULAR EVENTS
The HOPE trial
Study population
9297 patients with vascular diseases or diabetes
plus another cardiovascular risk factor
Follow-up
4.5 years
R.R. (95 C.I.)
Renal insufficiency Microalbuminuria Renal
insufficiency and microalbuminuria Coronary
artery disease
Increased risk
1
1.25
1.5
2.0
2.5
0.5
The predictive value of renal insufficiency and
microalbuminuria is comparable to that of
pre-existing coronary artery disease and is even
superior when they are present together
Jusuf et al., Am Int Med, 2001
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THE GLOBAL BURDEN OF DIABETES (2000-2030)
52.4
42.3
30.7
18.6
33.8
80.9
16.7
71
127
22.8
102
28.3
255
9.1
32.9
211
18.2
0.9
1.6
78
81
In million subjects
World
Developed
Developing
2000 2030
154 m 370 m
55 m 84 m
99 m 286 m
WHO, March 2003
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Cost of RRT

• Hemodialysis
• 40,000 - 60,000
• Peritoneal dialysis
• 20,000
• Renal transplantation
• 15,000 (first year)

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PREDICTED DIALYSIS COST OF APPROXIMATELY 1.1
TRILLION FOR THE COMING DECADE
1200
1000
800
Ten year medical costs of dialysis population (
billions)
600
400
200
0
1981-1990
1991-2000
2001-2010


Lysaght et al., J Am Soc Nephrol, 2002
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COST OF DIALYSIS AS A SHARE OF TOTAL HEALTH COSTS
Total dialysis costs
Healthcare costs ()
Dialysis patients ( population)
UK Switzerland Germany France Italy Belgium
300,000,000 130,000,000 3,000,000,000 7,000,000,00
0 2,000,000,000,000 6,800,000,000
SF DM FF L BF
0.7 1.0 1.3 1.5 1.5 1.8
0.022 0.03 0.05 0.035 0.06 0.037
1994 data
De Vecchi et al., 1999
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Cost of RRT

• Hemodialysis
• 40,000 - 60,000
• Peritoneal dialysis
• 20,000
• Renal transplantation
• 15,000 (first year)

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World Bank Economic Classification
Group N.o of Population Annual GNI
Countries billion per capita, High
56 0.93 gt9076 Upper middle 34
0.57 2936 -9076 Low middle 54 2.28
735- 2936 Low 64 2.05 lt735
http//www.worldbank.org/
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Comparative statistic of developed and developing
countries
Parameter Developed Developing Population,
billions 0.93 4.9 Urban, 74 31 Life
expectancy, years 78 62 Birth
rate 14 32 Infant mortality
rate 13 77 GNP per capita, US 25,700 1230
Kher, KI 2002
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Moeller et al. NDT 2002
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• In Central Estern Europe during the period
  1990-1996 there has been
• 56 increase of dialysis center
• 78 of hemodialysis patients
• 306 of peritoneal dialysis patients
• However the prevalence and incidence of RRT is
  significant lower than in European Union

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NATIONS DELIVER CARE FOR ESRD AS A FUNCTION OF
THEIR ECONOMY
30000
EU countries
25000
20000
GNP ( per capita)
15000
10000
East Europe countries
5000
0
0
200
400
600
800
1000
Prevalence RRT pmp
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NATIONS DELIVER CARE FOR ESRD AS A FUNCTION OF
THEIR ECONOMY
The case of Latin America
Zatz et al, Kidney Int, 2003
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MUCH LESS IS KNOWN ABOUT THE INCIDENCE AND
PREVALENCE OF CHRONIC KIDNEY DISEASE IN
PRE-DIALYSIS PHASE
Third National Health And Nutrition Examination
Survey (NHANES III)Estimate among US population
Stage Est.GFR Prevalence No. 1
gt90 3.3 5.9 million 2 60-89
3.0 5.3 million 3 30-59 4.3 7.6
million 4 15-29 0.2 0.4 million 5
lt15 0.2 0.3 million TOTAL
11.0 19.2 million
Coresh et al., Am J Kidney Dis, 2003
51

• Event though it does not rank at the highest
  places, the global burden of Chronic Kidney
  Disease is significant and is probably
  underestimated

52

• The number of patients with kidney failure
  requiring renal replacement therapy is
  relentlessly increasing throughout the world, and
  the growth has not apparently reached a steady
  state

53

• Renal replacement therapy is so costly that there
  is minimal probability for the vast majority of
  the worlds population to take advantage from it