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Chronic renal diseases as a public health problem

Chronic renal diseases as a public health problem. Epidemiology, Social and Economical Implications. Arrigo Schieppati Bellagio March 16, 2004. The Global Burden of Disease and Injury:

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Chronic renal diseases as a public health problem

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  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?path=evidence,burden&language=english

  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?path=evidence,burden&language=english

  4. GLOBAL BURDEN OF DISEASE: ANNUAL DEATHS

  5. 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 1.18 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

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

  11. 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

  12. 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

  14. Treatment modalities TX PD HD Moeller et al. NDT 2002

  15. 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

  16. 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 0 Moeller et al. NDT 2002

  17. 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

  18. 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

  19. 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 Cambodia 4 11 m Vietnam 5 78 m Singapore 716 3 m Myanmar 3 51 m Sitprija, Kidney Int 2003

  20. RRT in Asia • The Asian-Pacific Region (1998-2000) • 1.684.220.000 population ESRD patients 1998 2000 % change Thailand Philippines Malaysia Australia Korea Taiwan Japan New Zealand 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 1,325 35,5 19,2 17,3 6,1 7,7 4,2 5,3 7,8 Lee, Semin Nephrol, 2003

  21. RRT in North Africa COUNTRY ESRD Tot pop pmp Algeria 34 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

  22. RRT in Sub-Saharan Africa COUNTRY DIALYSIS POP. GEN.POP S.Africa 2200 43 m Nigeria 300 120 m Kenya 220 29 m Cote d’Ivoire 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

  23. Use of PD as RRT modality Source: USRDS 2003

  24. Transplant rates Source: USRDS 2003

  25. 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

  26. 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

  28. FIRST YEAR OUTCOME OF RRT IN INDIA Kher, Kidney Int, 2002

  29. 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

  31. 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

  32. 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

  34. 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

  35. 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

  36. 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 0.5 1 1.25 1.5 2.0 2.5 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

  37. 2000 2030 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

  38. Cost of RRT • Hemodialysis • $ 40,000 - 60,000 • Peritoneal dialysis • $ 20,000 • Renal transplantation • $15,000 (first year)

  39. $ $ $ 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

  40. 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 7,000,000,000 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 * 1994 data De Vecchi et al., 1999

  41. Cost of RRT • Hemodialysis • $ 40,000 - 60,000 • Peritoneal dialysis • $ 20,000 • Renal transplantation • $15,000 (first year)

  42. 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/

  43. 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

  44. Japan N.America EU Asia & Africa M.East L.America Moeller et al. NDT 2002

  45. 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

  46. 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

  47. NATIONS DELIVER CARE FOR ESRD AS A FUNCTION OF THEIR ECONOMY The case of Latin America Zatz et al, Kidney Int, 2003

  48. MUCH LESS IS KNOWN ABOUT THE INCIDENCE AND PREVALENCE OF CHRONIC KIDNEY DISEASE IN PRE-DIALYSIS PHASE Third National HealthAndNutrition Examination Survey (NHANES III)Estimate among US population Stage Est.GFR Prevalence No. 1 >90 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 <15 0.2% 0.3 million TOTAL 11.0% 19.2 million Coresh et al., Am J Kidney Dis, 2003

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