Chronic renal diseases as a public Chronic renal diseases as a public health problemhealth problem
Epidemiology, Social and Epidemiology, Social and Economical ImplicationsEconomical Implications
Arrigo Schieppati
Bellagio March 16, 2004
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?path=evidence,burden&language=english
According to the GBD estimates for the According to the GBD estimates for the year 2002, chronic kidney diseases year 2002, chronic kidney diseases ranked ranked 12th12th as a cause of Death as a cause of Death 17th17th as a cause of Disability as a cause of Disability
Adjusted Life Years (DALYs)Adjusted Life Years (DALYs)
http://www3.who.int/whosis/menu.cfm?path=evidence,burden&language=english
1 Cardiovascular diseases 16.654.9242 Infectious and parasitic diseases 11.122.1313 Malignant neoplasms 7.106.3544 Respiratory infections 3.844.7245 Respiratory diseases 3.696.3096 Unintentional injuries 3.562.0227 Perinatal conditions* 2.463.8678 Digestive diseases 1.962.5179 Intentional injuries 1.626.09310 Neuropsychiatric conditions 1.104.85911 Diabetes mellitus 986.83712 Genitourinary diseases 847.16813 Maternal conditions 510.19314 Congenital anomalies 493.40915 Nutritional deficiencies 474.66616 Endocrine disorders 242.70417 Other neoplasms 148.43818 Musculoskeletal diseases 106.42319 Skin diseases 68.81020 Sense organ diseases 3.20821 Oral conditions 1.627
GLOBAL BURDEN OF DISEASE: ANNUAL DEATHS
1 Infectious and parasitic diseases 3568244422 Neuropsychiatric conditions 1931359093 Cardiovascular diseases 1475410544 Unintentional injuries 1334677725 Perinatal conditions* 974226266 Respiratory infections 902518877 Malignant neoplasms 754069748 Sense organ diseases 693798189 Respiratory diseases 5505999510 Intentional injuries 4912312511 Digestive diseases 4630018212 Nutritional deficiencies 3407006313 Maternal conditions 3362454714 Musculoskeletal diseases 3016813615 Congenital anomalies 2740242816 Diabetes mellitus 1619078217 Genitourinary diseases 1521385418 Endocrine disorders 796559619 Oral conditions 737202120 Skin diseases 374944921 Other neoplasms 1745659
GLOBAL BURDEN OF DISEASE: DALYs
Regional distribution of Genito-urinary Regional distribution of Genito-urinary diseasesdiseases
WHO Region GU deaths % of all % of deathsdeaths 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 1.18 85%
South East Asia 206,136 1.41 50%
West Pacific 202,712 1.70 75%
http://www3.who.int/whosis/menu.cfm?path=evidence,burden&language=english
In the Global Burden of Disease report, renal In the Global Burden of Disease report, renal diseases are grouped under the item diseases are grouped under the item “Disease of the Genitourinary System”, “Disease of the Genitourinary System”, which is articulated into two categorieswhich is articulated into two categoriesNephrosis and nephritisNephrosis and nephritisBenign prostatic hypertrophyBenign prostatic hypertrophy
too generic terms for allowing full too generic terms for allowing full appreciation of the global burden of chronic appreciation of the global burden of chronic kidney diseaseskidney diseases
Other sources of InformationOther sources of Information
Renal Registries are the most valuable Renal Registries are the most valuable source of information on ESRD source of information on ESRD demographics, treatment practices, and demographics, treatment practices, and outcomeoutcome
They also provide a base for They also provide a base for international comparisons and aid international comparisons and aid understanding practice and policies understanding practice and policies variation in different part of the worldvariation in different part of the world
However...However...
Data collection and analysis requires Data collection and analysis requires extensive resources and often timely extensive resources and often timely reporting is difficult reporting is difficult
Information on ESRD from developing Information on ESRD from developing countries is even more difficult and countries is even more difficult and often relies on personal account of often relies on personal account of leading nephrologists or sporadic leading nephrologists or sporadic publicationspublications
http://www.ifrr.net/http://www.ifrr.net/ http://www.usrds.org/http://www.usrds.org/ http://www.era-edta-reg.org/index.jsphttp://www.era-edta-reg.org/index.jsp http://www.unifesp.br/dis/gamba/rgbrinti.htmhttp://www.unifesp.br/dis/gamba/rgbrinti.htm http://www.renalreg.com/http://www.renalreg.com/ http://www.quasi-niere.de/http://www.quasi-niere.de/ http://www.sin-ridt.org/sin-ridt/sin-ridt.org.htmhttp://www.sin-ridt.org/sin-ridt/sin-ridt.org.htm http://www.nephro.at/http://www.nephro.at/ http://www.nbvn.be/http://www.nbvn.be/ http://www.dns.suite.dk/dns.htmhttp://www.dns.suite.dk/dns.htm http://www.renine.nl/http://www.renine.nl/
InternationalInternational USAUSA EuropeEurope BrazilBrazil UKUK GermanyGermany ItalyItaly AustriaAustria BelgiumBelgium DenmarkDenmark The NetherlandsThe Netherlands
Renal Registries on the InternetRenal Registries on the Internet
In 2001 Fresenius Medical Care dialysis In 2001 Fresenius Medical Care dialysis network carried out a global survey on network carried out a global survey on RRT worldwideRRT worldwide
Data were collected through survey Data were collected through survey forms based on a catalogue of 12 items forms based on a catalogue of 12 items relevant to the treatment of ESRDrelevant to the treatment of ESRD
Moeller et al. NDT 2002
Countries surveydCountries surveyd 120120PopulationPopulation 5.7 billion (90% world pop) 5.7 billion (90% world pop)
Moeller et al. NDT 2002
People on RRT in 2001People on RRT in 2001
1 479 0001 479 000
Moeller et al. NDT 2002
Treatment modalitiesTreatment modalities
1.015.000
126.000
338.000
HDPD
TX
Moeller et al. NDT 2002
Regional ESRD distributionRegional 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
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
6–15a 1785 28.8 243 21
16–120a 3179 51.4 240 21
121–232a 503 8.1 0 0Moeller et al. NDT 2002
58% of dialysis population is treated in 5 58% of dialysis population is treated in 5 countries* with less than 12% of world countries* with less than 12% of world populationpopulation
The next 10 countries, ranked by size of The next 10 countries, ranked by size of dialysis population, accounted for 21% of dialysis population, accounted for 21% of global dialysis patients and represent 29% global dialysis patients and represent 29% of world populationof world population
* Japan, USA, Germany, Brazil, Italy* Japan, USA, Germany, Brazil, Italy
Moeller et al. NDT 2002
RRT in Latin AmericaRRT in Latin America
COUNTRY ESRD Tot poppmp
Argentina 271 33.4 mBolivia 16 7.9 mBrazil 162 159 mChile 215 13.8 mColombia 38 34.8 mEcuador 31.2 11.3 mMexico 140 94.2 mUruguay 498 3.1 mVenezuela 130 21.2m
Mazzucchi et al. NDT 1997
RRT in AsiaRRT in Asia
COUNTRY ESRD Tot poppmp
Thailand 96 62 mPhilippines 35 72 mMalaysia 262 23 mBrunei 1077 0.3 mKorea 584 48 mTaiwan 1359 22 mJapan 1623 127mCambodia 4 11 mVietnam 5 78 mSingapore 716 3 mMyanmar 3 51 m
Sitprija, Kidney Int 2003
RRT in AsiaRRT in Asia
The Asian-Pacific Region (1998-2000)•1.684.220.000 population
ESRD patients
4,401851
5,1395,977
26,03928,683
195,7561,229
5,9642,4866,0286,341
28,04429,888
206,1311,325
35,519,217,3
6,17,74,25,37,8
ThailandPhilippinesMalaysiaAustraliaKoreaTaiwanJapanNew Zealand
Lee, Semin Nephrol, 2003
1998 % change2000
RRT in North AfricaRRT in North Africa
COUNTRY ESRD Tot poppmp
Algeria 34 30.4 mEgypt 264 63.8 mLibya 30 5.5 mTunisia 430 9.6 mMorocco 52 28.7 m
Barsoum, Kidney Int, 2003
RRT in Sub-Saharan AfricaRRT in Sub-Saharan Africa
COUNTRY DIALYSIS POP. GEN.POPS.Africa 2200 43 mNigeria 300 120 mKenya 220 29 mCote d’Ivoire 130 15.5 mMauritania 50 2.5 mGhana 30 20 mCameroon 30 15.5 mSenegal 25 10 mEthiopia 5 75 m
Bamgboye, Kidney Int, 2003
Use of PD as RRT modalityUse of PD as RRT modality
0102030405060708090
100
Japan USA HongKong
UK NZ Mexico
Pts
on
PD
(%
)
Source: USRDS 2003
Transplant rates Transplant rates
0
10
20
30
40
50
60U
S
Au
stri
a
No
rway
Bel
giu
m
Sw
eed
en
Can
ada
Fin
lan
d
Au
stra
lia
Ital
y
Tai
wan
Tu
rkey
Ph
ilip
pin
es
Ru
ssia
Rat
e p
er m
illi
on
po
p
Source: USRDS 2003
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
Causes of ESRD in incident patientsCauses of ESRD in incident patients
EDTA registry includes: Spain, UK, Belgium,Denmark, Sweeden, Austria. Greece, Norway,
Netherlands, Finland
Incident patients with DiabetesIncident patients with Diabetes
05
101520253035404550
US
Pak
ista
n
Jap
an
Tai
wan
Can
ada
Fin
lan
d
Tu
rkey
Au
stra
lia
Ph
ilip
pin
es
Ital
y
No
rway
Ru
ssia
Source: USRDS 2003
In In INDIAINDIA approximately approximately 100,000100,000 pts pts develop ESRD every yeardevelop ESRD every year
1010 % consult nephrologist % consult nephrologist90009000 start RRT start RRT60%60% of them stop within of them stop within 33 months months17-2317-23% of those still on dialysis after 2 % of those still on dialysis after 2
months receive transplantationmonths receive transplantation
Kher, Kidney Int, 2002
Lost58%
Died13%
Tx17%
HD4%
PD2%
Irregular HD6%
FIRST YEAR OUTCOME OF RRT IN INDIA
Kher, Kidney Int, 2002
The number of patients treated for end-The number of patients treated for end-stage renal disease (ESRD) has stage renal disease (ESRD) has demonstrated continous growth since demonstrated continous growth since the establishment of dialysis and the establishment of dialysis and transplantation as life-sustaining transplantation as life-sustaining therapiestherapies
The growth of the number of ESRD The growth of the number of ESRD patients is 5 times greater than the patients is 5 times greater than the world population growth (1.3%)world population growth (1.3%)
There is no sign that the growth has There is no sign that the growth has reached a steady state in the next 20 reached a steady state in the next 20 yearsyears
Lysaght, J Am Soc Nephrol, 2002
GLOBAL MAINTENANCE DIALYSIS POPULATION FROM 1990 TO 2010GLOBAL MAINTENANCE DIALYSIS POPULATION FROM 1990 TO 2010
1990 2000 2010
426,000
1,490,000
2,500,000
PREVALENCE OF ESRD IN THE DEVELOPED COUNTRIES IS RAPIDLY INCREASING
1500
2000
1000
Pre
vale
nce
of
ES
RD
(p
atie
nts
/pm
p)
500
0
1131
1403
683
920
690788
1397
1642
USRDS, Report 2003
530 633650
841
1997
2001
America Europe Asia/Oceania
USA Canada Germany Italy Japan Australia
The reasons of this growth areThe reasons of this growth areGlobal ageingGlobal ageingMulti-morbid populationMulti-morbid populationHigher life-expectancy of ESRD patientsHigher life-expectancy of ESRD patients Increasing access of younger people in Increasing access of younger people in
countries in which RRT has been limited countries in which RRT has been limited until todayuntil today
WHY THE BURDEN OF CHRONIC KIDNEY DISEASE IS WHY THE BURDEN OF CHRONIC KIDNEY DISEASE IS
GROWING ? 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
PROJECTED CHANGES OF ISCHEMIC HEART DISEASE MORTALITY PROJECTED CHANGES OF ISCHEMIC HEART DISEASE MORTALITY
WORLDWIDEWORLDWIDE
DEVELOPINGCOUNTRIES
DEVELOPEDCOUNTRIES
0
1000
2000
3000
4000
5000
1990 2020
Yusuf et al., Circulation, 2001
Deaths (x 1000)
(1990 to 2020)
RENAL DISEASES ARE INDEPENDENT RISK FACTORS FOR CARDIOVASCULAR EVENTS
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
Renal insufficiency
Microalbuminuria
Renal insufficiency and microalbuminuria
Coronary artery disease
R.R. (95 % C.I.)
1 1.25 1.5 2.0 2.50.5
Increased risk
Jusuf et al., Am Int Med, 2001
Study population:
The HOPE trial
9297 patients with vascular diseases or diabetes plus another cardiovascular risk factor
Follow-up: 4.5 years
World
20002030
154 m370 m
55 m84 m
Developed Developing
99 m286 m
16.733.8
32.9
18.2
52.430.7
28.3
9.1
80.9
22.8
42.3
18.6
0.9 1.6
2000
2030
* In million subjects
102%
81%
71%
211%
255%
127%
78%
THE GLOBAL BURDEN OF DIABETES (2000-2030)THE GLOBAL BURDEN OF DIABETES (2000-2030)
WHO, March 2003
Cost of RRTCost of RRT
HemodialysisHemodialysis$ 40,000 - 60,000$ 40,000 - 60,000
Peritoneal dialysisPeritoneal dialysis$ 20,000$ 20,000
Renal transplantationRenal transplantation $15,000 (first year)$15,000 (first year)
Lysaght et al., J Am Soc Nephrol, 2002
1200
600
0
Te
n ye
ar
me
dic
al c
ost
s o
f d
ialy
sis
pop
ula
tion
$ (
bill
ions
)
1981-1990 1991-2000 2001-2010
800
1000
$
$
$
PREDICTED DIALYSIS COST OF APPROXIMATELY $ 1.1 TRILLION FOR PREDICTED DIALYSIS COST OF APPROXIMATELY $ 1.1 TRILLION FOR THE COMING DECADETHE COMING DECADE
400
200
COST OF DIALYSIS AS A SHARE OF TOTAL HEALTH COSTS
UK
Switzerland
Germany
France
Italy
Belgium
300,000,000
130,000,000
3,000,000,000
7,000,000,000
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
Total dialysis costs*
Healthcare costs (%)
Dialysis patients
(% population)
De Vecchi et al., 1999
* 1994 data
Cost of RRTCost of RRT
HemodialysisHemodialysis$ 40,000 - 60,000$ 40,000 - 60,000
Peritoneal dialysisPeritoneal dialysis$ 20,000$ 20,000
Renal transplantationRenal transplantation $15,000 (first year)$15,000 (first year)
World Bank Economic Classification World Bank Economic Classification
Group N.o of Population Annual GNI
Countries billion per capita, $
High 56 0.93 >9076
Upper middle 34 0.57 2936 -9076
Low middle 54 2.28 735- 2936
Low 64 2.05 <735
http://www.worldbank.org/
Comparative statistic of developed Comparative statistic of developed and developing countries 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
$0.00
$5,000.00
$10,000.00
$15,000.00
$20,000.00
$25,000.00
$30,000.00
$35,000.00
$40,000.00
0 500 1000 1500 2000
ESRD Prevalence (pmp)
GD
P p
er
cap
ita N.America
Japan
EU
L.America
M.East
Asia & Africa
Moeller et al. NDT 2002
In Central Estern Europe during the In Central Estern Europe during the period 1990-1996 there has been period 1990-1996 there has been 56% increase of dialysis center56% increase of dialysis center78% of hemodialysis patients78% of hemodialysis patients306% of peritoneal dialysis patients306% of peritoneal dialysis patients
However the prevalence and incidence However the prevalence and incidence of RRT is significant lower than in of RRT is significant lower than in European UnionEuropean Union
0
5000
10000
15000
20000
25000
30000
0 200 400 600 800 1000
Prevalence RRT pmp
GN
P (
$ p
er c
apit
a)
East Europe countries
NATIONS DELIVER CARE FOR ESRD AS A FUNCTION OF THEIR ECONOMY
EU countries
NATIONS DELIVER CARE FOR ESRD AS A FUNCTION OF THEIR ECONOMY
Zatz et al, Kidney Int, 2003
The case of Latin America
MUCH LESS IS KNOWN ABOUT THE INCIDENCE MUCH LESS IS KNOWN ABOUT THE INCIDENCE AND PREVALENCE OF CHRONIC KIDNEY DISEASE AND PREVALENCE OF CHRONIC KIDNEY DISEASE IN PRE-DIALYSIS PHASEIN PRE-DIALYSIS PHASE
Stage Est.GFR Prevalence No.
1 >90 3.3% 5.9 million2 60-89 3.0% 5.3 million3 30-59 4.3% 7.6 million4 15-29 0.2% 0.4 million5 <15 0.2% 0.3 million
TOTAL 11.0% 19.2 million
Coresh et al., Am J Kidney Dis, 2003
Third National Health And Nutrition Examination Survey (NHANES III)
Estimate among US population
Event though it does not rank at the Event though it does not rank at the highest places, the global burden of highest places, the global burden of Chronic Kidney Disease is significant Chronic Kidney Disease is significant and is probably underestimatedand is probably underestimated
The number of patients with kidney The number of patients with kidney failure requiring renal replacement failure requiring renal replacement therapy is relentlessly increasing therapy is relentlessly increasing throughout the world, and the growth throughout the world, and the growth has not apparently reached a steady has not apparently reached a steady statestate
Renal replacement therapy is so costly Renal replacement therapy is so costly that there is minimal probability for the that there is minimal probability for the vast majority of the world’s population to vast majority of the world’s population to take advantage from ittake advantage from it