GLOBAL 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 Asians
21 Europeans
14 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
ESRD is increasingly common worldwide
2,500,000
1,490,000
426,000
1990
2000
2010
6 S37
Lysaght, MJ. JASN 2002; 13:
GLOBAL TREATMENT FOR ESRD
60% treated in 5 countries
(Brazil, Germany, Italy, Japan, US)
Representing <12 % world population
Moeller S et al. NDT 2002;17:2071
GLOBAL TREATMENT FOR ESRD
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
Moeller S et al. NDT 2002;17:2071
GLOBAL TREATMENT FOR ESRD
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
Moeller S et al. NDT 2002;17:2071
Geographic variations in
the prevalence of ESRD, 2010
USRDS 2012 ADR
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
Prevalent patients on RRT and GDP per capita
2002
White et al, Bulletin WHO, March 2008
Outcome of chronic HD in Nigeria
Mortality
< 1 mth
1-3 mths
3-6 mths
6-9 mths
9-12 mths
Reasons for stopping dialysis in Nigeria
Ulasi, Ijoma J Trop Med, 2010, 50:1957
‘BRIC’ COUNTRIES
Brazil
Russia
India
China
RRT in Mainland China
HD
PD
TRANSPLANTATION
20-30%
5,500
162,090
10%
5,500
127,451
17,280
104,671
22,000
134,591
Prevalence of RRT in some Asian
countries
2500
(pmp)
2219
2288
2120
2060
1999
2000
1900
1797
1852 1882
1956
1500
1000
878
928
970
1002 1027
500
0
HK
Taiwan
Japan
18
Prevalence of RRT in some Asian
countries
2500
(pmp)
2219
2288
2120
2060
1999
2000
1900
1797
1852 1882
1956
1500
1000
878
928
970
1002 1027
500
33
0
1
HK
Taiwan
Japan
03
2
37
04
3
40
45
05
06 07
4
53
5
66 83 116
6
08 09
中国大陆 China
Mainland
19
7
10
DEVELOPING ECONOMIES
BRIC COUNTRIES
Brazil - Russia - India - China
What drives increases in RRT ?
Economic growth
Healthcare systems
Commercial influence
Population expectation
Physician reimbursement
ETHICAL DIALYSIS
Diligence is needed if
the rapid growth of dialysis
in some developing countries is
to proceed to the highest ethical standards
It is the responsibility of
the global nephrology community
to set the standards
ETHICAL DIALYSIS
Diligence is needed if
the rapid growth of dialysis
in some developing countries is
to proceed to the highest ethical standards
Task Force on Ethical Standards in Dialysis
2013
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
How do we interpret such growth
yet variablity ?
Success?
Failure?
Good care?
‘Rationing’ ?
All rates are unadjusted. Data from Argentina (2005–2007),
Japan, & Taiwan are dialysis only.
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.
USRDS 2012 ADR
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
Why are White Caucasians
protected from
Type
2 diabetes & ESRD ?
African
Caribbeans
Hispanics
Native Americans
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’
RENAL DISASTER RELIEF
TASK FORCE
The Fellowship
Program
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
UK
All rates are unadjusted. Data from Argentina (2005–2007),
Japan, & Taiwan are dialysis only.
USRDS 2012 ADR
Comparison of
unadjusted ESRD
incidence worldwide
The tide can be turned
UK
All rates are unadjusted. Data from Argentina (2005–2007),
Japan, & Taiwan are dialysis only.
USRDS 2012 ADR
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 pressures
Exploitation
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
Lower middle income countries
Bolivia - Moldova
Low income countries
Nepal
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
Diabetes
CKD
Cardiovascular
disease
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
RISKS
A change of message
Entry to ‘mainstream’
NCD policy
A ‘seat at the table’
We can discuss large
populations at risk
Chronic Kidney Disease – A VASCULAR DISEASE ?
GAIN
RISKS
A change of message
Entry to ‘mainstream’
NCD policy
CKD just a minor issue…
the ‘big boys’ do not want
a CKD diversion:
A ‘seat at the table’
We can discuss large
populations at risk
“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 diabetes
USRDS
‘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 diabetes
USRDS
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
Costa Rica, El Salvador, Nicaragua
Interstitial disease
Less at higher altitudes
Sugar cane workers
Not aristolichic acid
Not heavy metals
? adverse effects of
recurrent 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
Every ‘epidemic’ is a different detective story
Each ‘epidemic’ is a new opportunity
What may these ’epidemics’ tell us about
apparently sporadic cases of
chronic kidney disease of uncertain cause ?
SUSCEPTIBILITY TO KIDNEY DISEASE
or PROGRESSION OF KIDNEY DISEASE
Genetic ?
Environment ?
Fetal environment?
SUSCEPTIBILITY TO KIDNEY DISEASE
or PROGRESSION OF KIDNEY DISEASE
Genetic ?
Environment ?
Fetal environment?
BIRTHWEIGHT AND PROTEINURIA IN AUSTRALIAN ABORIGINALS
25% of Aborigines have birthweight < 2500gm
Hoy 2000 NDT;15:1293
PREVALENCE OF RENAL DISEASE
IN DEPRIVED 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
ACUTE KIDNEY INJURY WORLDWIDE
Very limited epidemiological data
HOW DOES AKI DIFFER
IN THE DEVELOPING WORLD ?
Sepsis
Critical care
Vascular disease
AKI
HOW DOES AKI DIFFER
IN THE DEVELOPING WORLD ?
Sepsis
Critical care
Vascular disease
AKI
Communicable
Disease
Obstetric
complications
PREVENTION OF AKI
Sepsis
Critical care
Vascular disease
AKI
•
•
•
•
Clean water
Malaria control
HIV control
Immunisations
Communicable
Disease
• Maternity care
Obstetric
complications
TREATMENT OF AKI IN THE DEVELOPING WORLD
Treatment including acute dialysis (usually PD)
• saves young lives
• is cost effective
• gives major health gain
AKI
Communicable
Disease
Obstetric
complications
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
PHYSICIANS WHO HAVE LEFT THEIR HOME COUNTRY
OECD countries
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 NEPHROLOGISTS
IN INDIA ?
The attractions of private hospitals
The challenge for academic medicine
ISN FELLOWSHIP PROGRAMME
Low & 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
Comparison of
unadjusted ESRD
incidence worldwide
The tide can be turned
All rates are unadjusted. Data from Argentina (2005–2007),
Japan, & Taiwan are dialysis only.
USRDS 2012 ADR
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
ISN CKD Policy Task Force (2013)
M Tonelli
S Agarwal
A Cass
G Garcia Garcia
V Jha
S Naicker
HY Wang
C-W Yang
D O’Donoghue
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 ON
NON-COMMUNICABLE DISEASE
19-21 September 2011
UNITED NATIONS HIGH LEVEL MEETING ON
NON-COMMUNICABLE DISEASE
19-21 September 2011
A meeting of member states
UNITED NATIONS HIGH LEVEL MEETING ON
NON-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 ON
NON-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 ON
NON-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 ON
NON-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 countries
and that these diseases share common risk factors
and can benefit from common responses
to non-communicable diseases”.
UNITED NATIONS HIGH LEVEL MEETING ON
NON-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 countries
and that these diseases share common risk factors
One small
step …….
and can benefit
from common
responses
to non-communicable diseases”.
UNITED NATIONS HIGH LEVEL MEETING ON
NON-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 countries
and 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 water
Malaria control
HIV control
Immunisations
Maternity care
FUTURE PREVALENCE OF KIDNEY DISEASE
Implications for health policy
Interventions to control or reduce obesity
…. will eventually help to
reduce the incidence of CKD
PREVALENCE OF CKD IN DISADVANTAGED POPULATIONS
Implications for health policy
In very deprived populations
health improvement
may paradoxically increase CKD
PREVALENCE OF CKD IN DISADVANTAGED POPULATIONS
Implications for health policy
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 CKD IN DISADVANTAGED POPULATIONS
Implications for health policy
Any social, economic, or political changes
which increase population survival
will have a major effect on the prevalence of ESRD
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