chronic renal diseases as a public health problem epidemiology, social and economical implications...

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)


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%


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)


People on RRT in 2001People on RRT in 2001

1 479 0001 479 000


Treatment modalitiesTreatment modalities

1.015.000

126.000

338.000

HDPD

TX


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


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


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


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


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


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

chronic renal diseases as a public health problem epidemiology, social and economical implications...

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