global nephrology osman lecture 2013 john feehally
TRANSCRIPT
GLOBAL NEPHROLOGYGLOBAL NEPHROLOGY
OSMAN LECTURE 2013
John Feehally
If you could fit the entire population of the world into a village consisting of 100 people, maintaining the proportions of all the people living on Earth, that village would consist of
57 Asians21 Europeans14 Americans (North, Central and South) 8 Africans
6 people would possess 59% of the wealth and they would all come from the USA
80 would live in poverty 70 would be illiterate
50 would suffer from hunger and malnutrition
1 would own a computer
1 would have a university degree
RENAL REPLACEMENT THERAPY FOR END-STAGE RENAL DISEASE
Dialysis and kidney transplant
…are a fantastic success story
Government Attitudes to Kidney Disease
Until ~ 10 years ago ……
They were driven by concern
about the cost of renal replacement therapy
and
were pleased that kidney disease was uncommon
6Lysaght, MJ. JASN 2002; 13: S37
1990 2000 2010
426,000
1,490,000
2,500,000
ESRD is increasingly common worldwide
GLOBAL TREATMENT FOR ESRD
Moeller S et al. NDT 2002;17:2071
60% treated in 5 countries (Brazil, Germany, Italy, Japan, US)
Representing <12 % world population
GLOBAL TREATMENT FOR ESRD
Moeller S et al. NDT 2002;17:2071
60% treated in 5 countries (Brazil, Germany, Italy, Japan, US)
Representing <12 % world population
20% in next 10 countries(Argentina, China, Egypt, France, Korea, Mexico,
Spain, Taiwan, Turkey, UK)
Representing 29% world population
GLOBAL TREATMENT FOR ESRD
Moeller S et al. NDT 2002;17:2071
60% treated in 5 countries (Brazil, Germany, Italy, Japan, US)
Representing <12 % world population
20% in next 10 countries(Argentina, China, Egypt, France, Korea, Mexico,
Spain, Taiwan, Turkey, UK)
Representing 29% world population
Remaining 20% in over 100 countries
Representing > 50% world population
USRDS 2012 ADR
Geographic variations in the prevalence of ESRD, 2010
Data presented only for countries from which relevant information was available. All rates unadjusted. Latest data for Singapore & Morelos (Mexico) are for 2009 . Data for France include 23 regions. Data for Belgium & for England/Wales/Northern Ireland do not include patients younger than 18.
‘PREVALENCE’ OF ESRD
Usually defined by number of patients on RRT
Transplanted patients included in most (but not all) datasets
Does not quantify duration of RRT
Assumes acceptance rate = demand
Does not assess equity of access
WORLD BANK CLASSIFICATION OF ECONOMIES
White et al, Bulletin WHO, March 2008
Prevalent patients on RRT and GDP per capita2002
Outcome of chronic HD in NigeriaMortality
< 1 mth 1-3 mths 3-6 mths 6-9 mths 9-12 mths
Percent mortality
Reasons for stopping dialysis in Nigeria
Ulasi, Ijoma J Trop Med, 2010, 50:1957
‘BRIC’ COUNTRIES
BrazilRussiaIndiaChina
RRT in Mainland China
HD PD TRANSPLANTATION
10%
20-30%
104,671
134,59117,280
22,0005,500
5,500
127,451
162,090
Prevalence of RRT in some Asian countries
18
香港 2003
香港 2004
香港 2005
香港 2006
香港 2007
台湾 2003
台湾 2004
台湾 2005
台湾 2006
台湾 2007
日本 2003
日本 2004
日本 2005
日本 2006
日本 2007
0
500
1000
1500
2000
2500
878 928 970 1002 1027
19001999
21202219
2288
17971852 1882
19562060(pmp)
HK JapanTaiwan
Prevalence of RRT in some Asian countries
19
香港 2003
香港 2004
香港 2005
香港 2006
香港 2007
台湾 2003
台湾 2004
台湾 2005
台湾 2006
台湾 2007
日本 2003
日本 2004
日本 2005
日本 2006
日本 2007
0
500
1000
1500
2000
2500
878 928 970 1002 1027
19001999
21202219
2288
17971852 1882
19562060(pmp)
HK Japan
1 2 3 4 5 6 7 8
中国大陆
03 04 05 06 07 08 09 10
33 37 40 45 53 66 83 116
Taiwan Mainland China
What drives increases in RRT ?
Economic growth
Healthcare systems
Commercial influence
Population expectation
Physician reimbursement
DEVELOPING ECONOMIESBRIC COUNTRIES
Brazil - Russia - India - China
Diligence is needed if the rapid growth of dialysis
in some developing countries isto proceed to the highest ethical standards
ETHICAL DIALYSIS
It is the responsibility of the global nephrology community
to set the standards
Diligence is needed if the rapid growth of dialysis
in some developing countries isto proceed to the highest ethical standards
ETHICAL DIALYSIS
Task Force on Ethical Standards in Dialysis2013
USRDS 2012 ADR
Comparison of unadjusted ESRD prevalence worldwide
All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.
USRDS 2012 ADR
Comparison of unadjusted ESRD prevalence worldwide
All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.
How do we interpret such growth yet variablity ?
Success?
Failure?
Good care?
‘Rationing’ ?
USRDS 2012 ADR
Percentage of incident patients with ESRD due to diabetes, 2010
Data presented only for countries from which relevant information was available. All rates unadjusted. ^UK: England, Wales, & Northern Ireland (Scotland data reported separately). Data for Belgium & England/Wales/Northern Ireland do not include patients younger than 18. *Latest data for Singapore & Morelos (Mexico) are for 2009. Data for France include 23 regions in 2010.
RACIAL SUSCEPTIBILITY TO KIDNEY DISEASE
UNITED KINGDOM
Type 2 diabetics of South Asian origin
Incidence of ESRD TEN TIMES HIGHER than
White type 2 diabetics
No diabetes
Incidence of ESRD 3-4 TIMES HIGHER than
Whites
RACIAL SUSCEPTIBILITY TO TYPE 2 DIABETIC KIDNEY DISEASE
South Asians
Pacific Islanders
Australian Aborigines
African Caribbeans
Hispanics
Native Americans
RACIAL SUSCEPTIBILITY TO TYPE 2 DIABETIC KIDNEY DISEASE
South Asians
Pacific Islanders
Australian Aborigines
African Caribbeans
Hispanics
Native Americans
Why are White Caucasians protected from Type 2 diabetes & ESRD ?
ABORIGINAL AUSTRALIANS
SOCIO-ECONOMIC DISADVANTAGE AND ESRD
Cass A et al Ethnicity & Disease 2002; 12: 373
However “successful” a dialysis programme may be….
….. dialysis patients are uniquely vulnerable to
‘events beyond our control’
USRDS 2012 ADR
Comparison of unadjusted ESRD prevalence worldwide
All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.
USRDS 2012 ADR
Comparison of unadjusted ESRD incidence worldwide
All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.
UK
USRDS 2012 ADR
Comparison of unadjusted ESRD incidence worldwide
All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.
UK
The tide can be turned
KIDNEY TRANSPLANTATION
The underused option
Deceased and living donor
Cost effective
Affordable in some countries where dialysis is not
KIDNEY TRANSPLANTATION
The underused option
Deceased and living donor
Cost effective
Affordable in some countries where dialysis is not
BUT Cultural influences
Commercial pressuresExploitation
Transplant tourism
Chronic Kidney Disease
Only 10 years since the
K/DOQI Classification of Chronic Kidney Disease
was first published
PREVALENCE OF CKD
Cautions about the data…..
Population specific accuracy of estimating equations for GFR
CKD defined by a single test ?
General population or high risk population tested ?
Demographics ?
PREVALENCE OF CKD
High income countries
USA - UK
PREVALENCE OF CKD
High income countries
USA - UK
Upper middle income countries
Belarus - China - Mexico
Low income countries
Nepal
Lower middle income countries
Bolivia - Moldova
PREVALENCE OF CKD SIMILAR IN ALL COUNTRIES TESTED
Defined by eGFR < 60 and/or proteinuria
4 – 7 % of the population
Graded risk for progression to ESRD
Graded risk for cardiovascular mortality
CKD often coexists with other NCDs
Hypertension
Cardiovascular disease
CKD
Diabetes
Chronic Kidney Disease – A VASCULAR DISEASE ?
Chronic Kidney Disease – A VASCULAR DISEASE ?
GAIN
Entry to ‘mainstream’ NCD policy
A ‘seat at the table’
We can discuss large populations at risk
Chronic Kidney Disease – A VASCULAR DISEASE ?
GAIN
Entry to ‘mainstream’ NCD policy
A ‘seat at the table’
We can discuss large populations at risk
RISKS
A change of message
Chronic Kidney Disease – A VASCULAR DISEASE ?
GAIN
Entry to ‘mainstream’ NCD policy
A ‘seat at the table’
We can discuss large populations at risk
RISKS
A change of message
CKD just a minor issue… the ‘big boys’ do not want
a CKD diversion:
“If we sort out diabetes and hypertension… that will deal with the CKD
problem”
‘Chronic Kidney Disease’
CKD as a vascular disease
But NOT ONLY a vascular disease
‘Chronic Kidney Disease’
CKD as a vascular disease ….. but NOT ONLY a vascular disease
United States
28% of those with CKD do not have hypertension, or diabetesUSRDS
‘Chronic Kidney Disease’
CKD as a vascular disease ….. but NOT ONLY a vascular disease
United States
28% of those with CKD do not have hypertension, or diabetesUSRDS
China – Mongolia - Nepal
43% of those with CKD do not have cardiovascular disease, hypertension, or diabetes
Sharma SK et al. AJKD 2010; 56: 915
‘Chronic Kidney Disease’
Up to ~40% of those with CKD do not have
cardiovascular disease, hypertension, or diabetes
Communicable disease
Glomerulonephritis
Hereditary/congenital diseases
Stones
Environmental factors
‘Chronic Kidney Disease’
Up to 40% of those with CKD do not have
cardiovascular disease, hypertension, or diabetes
Communicable disease
Glomerulonephritis
Hereditary/congenital diseases
Stones
Environmental factors
BALKAN ENDEMIC NEPHROPATHY
A – AAristolochic acid nephropathy
Epidemic of CKD in Sri Lanka: known since 2008
Low income agricultural communities
Limited access to health care
Clinical (and some biopsy evidence) of interstitial disease
Epidemic of CKD in Sri Lanka: known since 2008
Low income agricultural communities
Limited access to health care
Clinical (and some biopsy evidence) of interstitial disease
Sri Lankan government initiative
WHO support
Epidemiology, public health, agriculture, soil science, etc
Epidemic of CKD in Sri Lanka: known since 2008
NOT Aristolochic acid
Growing evidence of
Heavy metal intoxication – cadmium, arsenic
in food, tobacco, soil, agrochemicals
Epidemic of CKD in Sri Lanka: known since 2008
NOT Aristolochic acid
Growing evidence of
Heavy metal intoxication – cadmium, arsenic
in food, tobacco, soil, agrochemicals
Needs a multi-prolonged prevention initiative
Epidemic of CKD in Central America
Not aristolichic acid
Not heavy metals
Costa Rica, El Salvador, NicaraguaInterstitial disease
Less at higher altitudesSugar cane workers
? adverse effects ofrecurrent episodic dehydration
Epidemics of CKD with environmental factors
Every ‘epidemic’ is a different detective story
Each ‘epidemic’ is a new opportunity
Epidemics of CKD with environmental factors
What may these ’epidemics’ tell us about
apparently sporadic cases of
chronic kidney disease of uncertain cause ?
Every ‘epidemic’ is a different detective story
Each ‘epidemic’ is a new opportunity
Genetic ? Environment ?
SUSCEPTIBILITY TO KIDNEY DISEASE or PROGRESSION OF KIDNEY DISEASE
Fetal environment?Fetal environment?
Genetic ? Environment ?
SUSCEPTIBILITY TO KIDNEY DISEASE or PROGRESSION OF KIDNEY DISEASE
Fetal environment?Fetal environment?
BIRTHWEIGHT AND PROTEINURIA IN AUSTRALIAN ABORIGINALS
25% of Aborigines have birthweight < 2500gm
Hoy 2000 NDT;15:1293
In very deprived populations health improvement
may paradoxically increase CKD
Fall in perinatal mortality will increase survival of low birthweight babies
Adults will survive longer to get CKD
In very deprived populations health improvement
may paradoxically increase CKD
Fall in perinatal mortality will increase survival of low birthweight babies
Adults will survive longer to get CKD
PREVALENCE OF RENAL DISEASE IN DEPRIVED POPULATIONS
ACUTE KIDNEY INJURY WORLDWIDE
Very limited epidemiological data
AKI
SepsisCritical care
Vascular disease
HOW DOES AKI DIFFER IN THE DEVELOPING WORLD ?
Communicable Disease
HOW DOES AKI DIFFER IN THE DEVELOPING WORLD ?
AKI
Obstetric complications
SepsisCritical care
Vascular disease
Communicable Disease
PREVENTION OF AKI
AKI
Obstetric complications
SepsisCritical care
Vascular disease
• Clean water• Malaria control• HIV control• Immunisations
• Maternity care
Communicable Disease
TREATMENT OF AKI IN THE DEVELOPING WORLD
AKI
Obstetric complications
Treatment including acute dialysis (usually PD)• saves young lives• is cost effective
• gives major health gain
WHERE ARE THE PHYSICIANS ?
NON-PHYSICIAN CLINICIANS AND PHYSICIAN ‘DENSITIES’IN SUB-SAHARAN AFRICA 2003
WHO: World Health Report 2006
Doctors trained in sub Saharan Africa working in OECD countriesPHYSICIANS WHO HAVE LEFT THEIR HOME COUNTRY
WHERE ARE THE NEPHROLOGISTS ?
WHERE ARE THE NEPHROLOGISTS ?
There are more nephrologists of Indian origin in North America than in India
WHERE ARE THE NEPHROLOGISTS ?
There are more nephrologists of Indian origin in North America than in India
..... A LOT more
WHERE ARE THE NEPHROLOGISTSIN INDIA ?
The attractions of private hospitals
The challenge for academic medicine
ISN FELLOWSHIP PROGRAMMELow & Middle Income Countries
Are we promoting the ‘brain drain’ ?
SUB-SAHARAN AFRICA
• Fellowships in South Africa
• >95% return rate
ISN Global Outreach (GO)Fellowships
Sister Renal Centers
Continuing Medical Education (CME) meetings
Educational Ambassadors
GOVERNMENT ATTITUDES TO KIDNEY DISEASE
Can they be influenced?
Government Approaches to Health Issues
Some generalisations ……..
Governments are concerned about common problems
Governments are concerned about high cost problems
Governments want hard epidemiological data
Governments want evidence of success
Governments want hard financial data
USRDS 2012 ADR
Comparison of unadjusted ESRD incidence worldwide
All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.
The tide can be turned
UK
Advocacy for Chronic Kidney Disease
CKD is a vascular disease
…. but so much more
ADVOCACY
The Declaration of Istanbul
Against
Organ Trafficking and Transplant Tourism
How to advocate for the inclusion of CKD
in a national non-communicable chronic disease program
M Tonelli S Agarwal A Cass G Garcia Garcia V Jha
S Naicker HY Wang C-W Yang D O’Donoghue
ISN CKD Policy Task Force (2013)
Kidney disease: common – harmful - treatable
World Kidney Day - AWARENESS
• POLICY MAKERS – government & politicians
• OTHER TARGET GROUPS – General public– High risk individuals– Health professionals
14 March 2013
ACUTE KIDNEY INJURY
14 March 2013
ACUTE KIDNEY INJURY
INTERNATIONAL ATTITUDES TO KIDNEY DISEASE
Can they be influenced?
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
A meeting of member states
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
A meeting of member states
Political statement which would follow the meeting already drafted by May 2011
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
A meeting of member states
Political statement which would follow the meeting already drafted by May 2011
No mention of kidney disease
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
LOBBYING
ISN networks achieved explicit support for CKD from a number of health ministers
…….communicated to WHO ahead of the High-level Meeting
….. including health ministers of
China, Ethiopia, India, Mexico, Taiwan, Turkey, USA
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
The final Political Statement
Paragraph 19:
“ the member states of the UN General Assembly .....recognize that renal, oral and eye diseases
pose a major health burden for many countriesand that these diseases share common risk factors
and can benefit from common responses to non-communicable diseases”.
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
The final Political Statement
Paragraph 19:
“ the member states of the UN General Assembly .....recognize that renal, oral and eye diseases
pose a major health burden for many countriesand that these diseases share common risk factors
and can benefit from common responses to non-communicable diseases”.
One small step …….
UNITED NATIONS HIGH LEVEL MEETING ONNON-COMMUNICABLE DISEASE
19-21 September 2011
The final Political Statement
Paragraph 19:
“ the member states of the UN General Assembly .....recognize that renal, oral and eye diseases
pose a major health burden for many countriesand that these diseases share common risk factors
and can benefit from common responses to non-communicable diseases”.
January 2012
ISN IS IN ‘OFFICIAL RELATIONS’ WITH WORLD HEALTH ORGANISATION
‘
This follows several years of ISN working with WHO
.... and will increase the influence of the voice for kidney disease
• At the WHO World Health Assembly
• Through joint projects with WHO
The Worldwide Burden of CKD & ESRD
What is modifiable ?
PREVENTION OF AKI
Clean waterMalaria control
HIV controlImmunisations
Maternity care
FUTURE PREVALENCE OF KIDNEY DISEASE
Interventions to control or reduce obesity
…. will eventually help to reduce the incidence of CKD
Interventions to control or reduce obesity
…. will eventually help to reduce the incidence of CKD
Implications for health policy
PREVALENCE OF CKD IN DISADVANTAGED POPULATIONS
Implications for health policy
In very deprived populations health improvement
may paradoxically increase CKD
In very deprived populations health improvement
may paradoxically increase CKD
PREVALENCE OF CKD IN DISADVANTAGED POPULATIONS
In very deprived populations health improvement
may paradoxically increase CKD
Fall in perinatal mortality will increase survival of low birthweight babies
Adults will survive longer to get CKD
In very deprived populations health improvement
may paradoxically increase CKD
Fall in perinatal mortality will increase survival of low birthweight babies
Adults will survive longer to get CKD
Implications for health policy
PREVALENCE OF CKD IN DISADVANTAGED POPULATIONS
Any social, economic, or political changes
which increase population survival
will have a major effect on the prevalence of ESRD
Any social, economic, or political changes
which increase population survival
will have a major effect on the prevalence of ESRD
Implications for health policy
The test of our progress is not
whether we add more
to the abundance of those who have much
.........it is whether we provide enough
for those who have little
Franklin D Roosevelt