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:
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
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
GLOBAL BURDEN OF DISEASE: ANNUAL DEATHS
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Cardiovascular diseases
Infectious and parasitic diseases
Malignant neoplasms
Respiratory infections
Respiratory diseases
Unintentional injuries
Perinatal conditions*
Digestive diseases
Intentional injuries
Neuropsychiatric conditions
Diabetes mellitus
Genitourinary diseases
Maternal conditions
Congenital anomalies
Nutritional deficiencies
Endocrine disorders
Other neoplasms
Musculoskeletal diseases
Skin diseases
Sense organ diseases
Oral conditions
16.654.924
11.122.131
7.106.354
3.844.724
3.696.309
3.562.022
2.463.867
1.962.517
1.626.093
1.104.859
986.837
847.168
510.193
493.409
474.666
242.704
148.438
106.423
68.810
3.208
1.627
GLOBAL BURDEN OF DISEASE: DALYs
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Infectious and parasitic diseases
Neuropsychiatric conditions
Cardiovascular diseases
Unintentional injuries
Perinatal conditions*
Respiratory infections
Malignant neoplasms
Sense organ diseases
Respiratory diseases
Intentional injuries
Digestive diseases
Nutritional deficiencies
Maternal conditions
Musculoskeletal diseases
Congenital anomalies
Diabetes mellitus
Genitourinary diseases
Endocrine disorders
Oral conditions
Skin diseases
Other neoplasms
356824442
193135909
147541054
133467772
97422626
90251887
75406974
69379818
55059995
49123125
46300182
34070063
33624547
30168136
27402428
16190782
15213854
7965596
7372021
3749449
1745659
Regional distribution of Genito-urinary
diseases
WHO Region
GU deaths
% of all
deaths
Africa
105,338
0.98
21%
America
135,765
2.20
76%
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%
East Mediterran
% of deaths
due to all NCD
http://www3.who.int/whosis/menu.cfm?path=evidence,burden&language=english

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
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

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

Renal Registries on the Internet

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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/
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International
USA
Europe
Brazil
UK
Germany
Italy
Austria
Belgium
Denmark
The Netherlands
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
Countries surveyd 120
Population
5.7 billion (90% world pop)
Moeller et al. NDT 2002
People on RRT in 2001
1 479 000
Moeller et al. NDT 2002
Treatment modalities
338.000
TX
PD
HD
126.000
1.015.000
Moeller et al. NDT 2002
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
Country
Pop.
% of world
(million)
pop.
Dialysis
% of dialysis
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
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
RRT in Latin America
COUNTRY
ESRD
Tot pop
pmp
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Mexico
Uruguay
Venezuela
271
16
162
215
38
31.2
140
498
130
33.4 m
7.9 m
159 m
13.8 m
34.8 m
11.3 m
94.2 m
3.1 m
21.2m
Mazzucchi et al. NDT 1997
RRT in Asia
COUNTRY
Thailand
Philippines
Malaysia
Brunei
Korea
Taiwan
Japan
Cambodia
Vietnam
Singapore
Myanmar
ESRD
pmp
96
35
262
1077
584
1359
1623
4
5
716
3
Tot pop
62 m
72 m
23 m
0.3 m
48 m
22 m
127m
11 m
78 m
3 m
51 m
Sitprija, Kidney Int 2003
RRT in Asia
The Asian-Pacific Region (1998-2000)
•1.684.220.000 population
ESRD patients
Thailand
Philippines
Malaysia
Australia
Korea
Taiwan
Japan
New Zealand
1998
2000
% change
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
RRT in North Africa
COUNTRY
ESRD
pmp
Tot pop
Algeria
Egypt
Libya
Tunisia
Morocco
34
264
30
430
52
30.4 m
63.8 m
5.5 m
9.6 m
28.7 m
Barsoum, Kidney Int, 2003
RRT in Sub-Saharan Africa
COUNTRY
S.Africa
Nigeria
Kenya
Cote d’Ivoire
Mauritania
Ghana
Cameroon
Senegal
Ethiopia
DIALYSIS POP.
2200
300
220
130
50
30
30
25
5
GEN.POP
43 m
120 m
29 m
15.5 m
2.5 m
20 m
15.5 m
10 m
75 m
Bamgboye, Kidney Int, 2003
Use of PD as RRT modality
Pts on PD (%)
100
90
80
70
60
50
40
30
20
10
0
Japan
USA
Hong
Kong
UK
NZ
Mexico
Source: USRDS 2003
Russia
Philippines
Turkey
Taiwan
Italy
Australia
Finland
Canada
Sweeden
Belgium
Norway
Austria
US
Rate per million pop
Transplant rates
60
50
40
30
20
10
0
Source: USRDS 2003
Causes of ESRD in incident patients
GN
DN
HT
RVD PKD PN
Europe*
7-20 15-33 4-24 0-13 5-11
Latin America
8-35 11-51
Australia
26
26
16
6
4
USA
9
44
27
2
2
EDTA registry includes:
11-22
Spain, UK, Belgium,Denmark, Sweeden, Austria. Greece, Norway,
Netherlands, Finland
5-10
1-6.5 3.9-7.5
Russia
Norway
Italy
Philippines
Australia
Turkey
Finland
Canada
Taiwan
Japan
Pakistan
US
Incident patients with Diabetes
50
45
40
35
30
25
20
15
10
5
0
Source: USRDS 2003
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
FIRST YEAR OUTCOME OF RRT IN INDIA
HD
4%
PD
2%
Tx
17%
Irregular HD
6%
Lost
58%
Died
13%
Kher, Kidney Int, 2002

The number of patients treated for endstage renal disease (ESRD) has
demonstrated continous growth since
the establishment of dialysis and
transplantation as life-sustaining
therapies
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

GLOBAL MAINTENANCE DIALYSIS POPULATION FROM 1990 TO 2010
2,500,000
1,490,000
426,000
1990
2000
2010
Lysaght, J Am Soc Nephrol, 2002
PREVALENCE OF ESRD IN THE DEVELOPED COUNTRIES
IS RAPIDLY INCREASING
1997
Prevalence of ESRD (patients/pmp)
2001
2000
America
Europe
Asia/Oceania
1642
1500
1403
1000
1397
1131
920
841
650
500
788
683
690
530
633
0
USA
Canada
Germany
Italy
Japan
Australia
USRDS, Report 2003

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

WHY THE BURDEN
GROWING ?
OF
CHRONIC
KIDNEY
DISEASE
IS
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
WORLDWIDE
OF
ISCHEMIC
HEART
DISEASE
MORTALITY
(1990 to 2020)
Deaths (x 1000)
5000
DEVELOPING
COUNTRIES
4000
3000
DEVELOPED
COUNTRIES
2000
1000
0
1990
2020
Yusuf et al., Circulation, 2001
RENAL DISEASES ARE INDEPENDENT
CARDIOVASCULAR EVENTS
RISK
FACTORS
FOR
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 preexisting coronary artery disease and is even superior when they are present together
Jusuf et al., Am Int Med, 2001
THE GLOBAL BURDEN OF DIABETES (2000-2030)
30.7
52.4
42.3
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%
2000
81%
2030
* In million subjects
2000
2030
World
Developed
Developing
154 m
370 m
55 m
84 m
99 m
286 m
WHO, March 2003
Cost of RRT

Hemodialysis


Peritoneal dialysis


$ 40,000 - 60,000
$ 20,000
Renal transplantation

$15,000 (first year)
PREDICTED DIALYSIS COST OF APPROXIMATELY $ 1.1 TRILLION FOR
THE COMING DECADE
Ten year medical costs of
dialysis population
$ ( billions)
1200
1000
800
600
400
200
0
1981-1990
1991-2000
2001-2010
Lysaght et al., J Am Soc Nephrol, 2002
COST OF DIALYSIS AS A SHARE OF TOTAL
HEALTH COSTS
Total dialysis
costs*
Healthcare
costs (%)
Dialysis
patients
(% population)
UK
300,000,000 £
Switzerland
130,000,000 SF
Germany
3,000,000,000 DM
France
7,000,000,000 FF
Italy
2,000,000,000,000 L
Belgium
6,800,000,000 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
Cost of RRT

Hemodialysis


Peritoneal dialysis


$ 40,000 - 60,000
$ 20,000
Renal transplantation

$15,000 (first year)
World Bank Economic Classification
Group
N.o of
Countries
Population
billion
Annual GNI
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
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
$40,000.00
GDP per capita
$35,000.00
Japan
$30,000.00
N.America
$25,000.00
EU
$20,000.00
Asia & Africa
$15,000.00
$10,000.00
M.East
$5,000.00
L.America
$0.00
0
500
1000
1500
2000
ESRD Prevalence (pmp)
Moeller et al. NDT 2002

In Central Estern Europe during the
period 1990-1996 there has been
56% increase of dialysis center
 78% of hemodialysis patients
 306% of peritoneal dialysis patients


However the prevalence and incidence
of RRT is significant lower than in
European Union
NATIONS DELIVER CARE FOR ESRD AS A FUNCTION
OF THEIR ECONOMY
GNP ($ per capita)
30000
EU countries
25000
20000
15000
10000
East Europe countries
5000
0
0
200
400
600
Prevalence RRT pmp
800
1000
NATIONS DELIVER CARE FOR ESRD AS A
FUNCTION OF THEIR ECONOMY
The case of Latin America
Zatz et al, Kidney Int, 2003
MUCH LESS IS KNOWN ABOUT THE INCIDENCE
AND PREVALENCE OF CHRONIC KIDNEY DISEASE
IN PRE-DIALYSIS PHASE
Third National Health And Nutrition Examination Survey (NHANES III)
Estimate among US population
Stage
1
2
3
4
5
TOTAL
Est.GFR
Prevalence
No.
>90
60-89
30-59
15-29
<15
3.3%
3.0%
4.3%
0.2%
0.2%
5.9 million
5.3 million
7.6 million
0.4 million
0.3 million
11.0%
19.2 million
Coresh et al., Am J Kidney Dis, 2003

Event though it does not rank at the
highest places, the global burden of
Chronic Kidney Disease is significant
and is probably underestimated

The number of patients with kidney
failure requiring renal replacement
therapy is relentlessly increasing
throughout the world, and the growth
has not apparently reached a steady
state

Renal replacement therapy is so costly
that there is minimal probability for the
vast majority of the world’s population to
take advantage from it