SM Gatmiri, MD, Nephrologist Imam Khomeini Hospital, In The Name of God CKD in Iran Presented by: SM Gatmiri, MD, Nephrologist Imam Khomeini Hospital, TUMSNRC

-Rising incidence & prevalence.    CKD -A worldwide problem. -Rising incidence & prevalence.

CKD Definition 1 -Kidney damage ≥3months, -Structural (pathological) or -Functional (composition of blood or urine) or -Imaging abnormalities -With or without decreased GFR. OR

CKD Definition 2 -Presence of GFR<60 mL/min/1.73 m2 ≥3 months, -With or without other signs of kidney damage.

Stage 1: NL GFR (>90 mL/min/1. 73 m2) & persistent albuminuria (1 Stage 1: NL GFR (>90 mL/min/1.73 m2) & persistent albuminuria (1.8% of the total US adult population). Stage 2: GFR 60 to 89 mL/min/1.73 m2 & persistent albuminuria (3.2%). Stage 3: GFR 30 & 59 mL/min/1.73 m2 (7.7%). Stage 4: GFR 15 & 29 mL/min/1.73 m2 (0.35%). Stage 5: GFR of <15 mL/min/1.73 m2 or ESRD (2.4%). 15.45%

The number of ESRD in US has increased from -10,000 in 1973 to -86,354 in 1983, & to -527,283 as of December 31, 2007.

In 2007 alone, 111,000 patients entered the US ESRD program In 2007 alone, 111,000 patients entered the US ESRD program. (Incidence: 440 PMP)

Patients with ESRD consume a disproportionate share of health care resources.

CKD, CHF & DM; Number of patients & costs; USA 2002 Numbers Costs 19% 5.8% 25.1% 20.7% 41.3% 48.1% 1.1% 7.8% Dialysis/Tx Total Medicare DM CHF CKD Collins AJ; USRDS database

The total cost of the ESRD program in the US was approximately $35 The total cost of the ESRD program in the US was approximately $35.32 billion in 2007.

However CKD in the US, is under- diagnosed & under-treated.

Iran Area: 1.648 million Sq Km Population : 68,017,860 Median Age : 24.23,Life Expectancy : 69.96 Total Health Expenditure of GDP : 6%

Prevalence : 357 PMP Incidence :66 PMP ESRD in Iran 12% CKD epidemiology in Iran Mitra Mahdavi-Mazdeh- Assessment of HD patients …, Iran ;NDT (2007)

Mean age difference in ESRD patients during last 10 years in Iran

Sex difference in ESRD patients during last 10 years

Causes of ESRD in the last 10 years in Iran

Sex difference in ESRD patients during last 10 years in Iran male to female ratio is 1.33. Sex difference in ESRD patients during last 10 years in Iran

Diabetes as the cause of ESRD in the last 10years

HTN & DM as the causes of ESRD in the last 10 years in Iran

The number Of ESRD will be doubled in next 10 years

Annual RRT Cost with total health expenditure of GDP of 6% -Dialysis sessions: 800Billion R for 13000 Pts (>60,000,000 R/Pts) -R Tx drugs =500 B R -for 12000 Pts (>40,000,000 R/Pts)

RRT program so far? CAPD HD centers Kidney Transplant

Time to change our approach: decrease ESRD number or its postponing

Population-Based Screening CKD in Iran: Mahdavi-Mazdeh :IJKD.vol:4,no:4, 2010

What is Solution? We Should push for a CKD education To take serious high NL Cr To take serious HTN &Diabetes management CKD should be viewed as the third part of the deadly triangle with DM and CVD affecting the health & welfare of the general population

What is Our Common Task As -Nephrologists -Internist -GPs -Health Authorities?

Education Public Education 1. Primordial Prevention : Healthy Diet, Changes in Social, Cultural and Personal Habits 2. Early Detection, Referral and Control of HTN & DM Public Education Professional (Health Care Personnel) Education

CKD Patients receiving ACE-Is/ARBs NHANES III 1988–1994 & NHANES 1999–2002 patients age 60 & older; patients with eGFRs of less than 15 ml/min/1.73 m2 are excluded. *Sample size less than 30, or coefficient of variation is not less than 30 percent.

Vascular Access: New Medical Evidence Form 2728 Data, May 2005-Dec 2006 82% of patients are using a catheter as their first outpatient access!!!! Only 13% of incident HD patients used a fistula as their first access. Assessment of HD patients …, Iran ;NDT (2007)

Vascular Access AVF use in Canadian prevalent (53%) and incident (26%)patients . In Europe [prevalent(74%), incident(50%) AVF is the advocated access route in Iran [prevalent (91%), incident(37.5%)in Tehran]. Assessment of HD patients …, Iran ;NDT (2007)

-CKD & ESRD is increased & highly prevalent Message: -CKD & ESRD is increased & highly prevalent -A strong CVD risk factor.

-We can detect CKD with simple tests & there are treatments for CKD. Message -We can detect CKD with simple tests & there are treatments for CKD.

Message: -ESRD is increasing, more than increases in number of HD facility & Tx.

Message -We should consider CKD prevention & place initial focus on strategies that slow disease progression to postpone RRT.