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 According to the GBD estimates for the year 2002, chronic kidney diseases ranked 12th as a cause of Death 12th as a cause of Death 17th as a cause of Disability Adjusted Life Years (DALYs) 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 RegionGU deaths% of all % of deaths deathsdue to all NCD Africa105,3380.9821% America135,7652.2076% East Mediterran 82,5711.9849% Europe112,0851.1885% South East Asia206,1361.4150% West Pacific202,7121.7075% 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 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 Nephrosis and nephritis Benign prostatic hypertrophy 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 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 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 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 Information on ESRD from developing countries is even more difficult and often relies on personal account of leading nephrologists or sporadic publications

10. http://www.ifrr.net/ http://www.ifrr.net/ http://www.usrds.org/ http://www.usrds.org/ http://www.era-edta-reg.org/index.jsp http://www.era-edta-reg.org/index.jsp http://www.unifesp.br/dis/gamba/rgbrinti.htm http://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.htm http://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.htm http://www.dns.suite.dk/dns.htm http://www.renine.nl/ http://www.renine.nl/  International  USA  Europe  Brazil  UK  Germany  Italy  Austria  Belgium  Denmark  The Netherlands Renal Registries on the Internet

11. In 2001 Fresenius Medical Care dialysis network carried out a global survey on RRT worldwide 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 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 surveyd120 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 HD PD TX Moeller et al. NDT 2002

15. Regional ESRD distribution Region Pop. GDP ESRD millionUS$ (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 6–15 a 1785 28.8 243 21 16–120 a 3179 51.4 240 21 121–232 a 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 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 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 * Japan, USA, Germany, Brazil, Italy Moeller et al. NDT 2002

18. RRT in Latin America COUNTRY ESRDTot pop pmp Argentina27133.4 m Bolivia 16 7.9 m Brazil 162159 m Chile21513.8 m Colombia 3834.8 m Ecuador31.211.3 m Mexico14094.2 m Uruguay498 3.1 m Venezuela130 21.2m Mazzucchi et al. NDT 1997

19. RRT in Asia COUNTRY ESRDTot pop pmp Thailand 9662 m Philippines 3572 m Malaysia 26223 m Brunei10770.3 m Korea 58448 m Taiwan135922 m Japan1623127m Cambodia 411 m Vietnam 578 m Singapore 716 3 m Myanmar 351 m Sitprija, Kidney Int 2003

20. RRT in Asia The Asian-Pacific Region (1998-2000) 1.684.220.000 population ESRD patients 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 Thailand Philippines Malaysia Australia Korea Taiwan Japan New Zealand Lee, Semin Nephrol, 2003 1998% change2000

21. RRT in North Africa COUNTRY ESRDTot pop pmp Algeria3430.4 m Egypt26463.8 m Libya305.5 m Tunisia4309.6 m Morocco5228.7 m Barsoum, Kidney Int, 2003

22. RRT in Sub-Saharan Africa COUNTRY DIALYSIS POP.GEN.POP S.Africa2200 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. GNDNHT RVDPKDPN Europe*7-2015-334-240-135-115-10 Latin America8-3511-51 11-221-6.53.9-7.5 Australia2626 1664 USA944 2722 Causes of ESRD in incident patients 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 In INDIA approximately 100,000 pts develop ESRD every year 10 % consult nephrologist 10 % consult nephrologist 9000 start RRT 9000 start RRT 60% of them stop within 3 months 60% of them stop within 3 months 17-23% of those still on dialysis after 2 months receive transplantation 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 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%) 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 There is no sign that the growth has reached a steady state in the next 20 years

31. Lysaght, J Am Soc Nephrol, 2002 GLOBAL MAINTENANCE DIALYSIS POPULATION FROM 1990 TO 2010 1990 2000 2010 426,000 1,490,000 2,500,000

32. PREVALENCE OF ESRD IN THE DEVELOPED COUNTRIES IS RAPIDLY INCREASING 1500 2000 1000 Prevalence of ESRD (patients/pmp) 500 0 1131 1403 683 920 690 788 1397 1642 USRDS, Report 2003 530 633 650 841 1997 2001 America EuropeAsia/Oceania USACanadaGermanyItalyJapanAustralia

33. The reasons of this growth are The reasons of this growth are Global ageing Global ageing Multi-morbid population Multi-morbid population Higher life-expectancy of ESRD patients Higher life-expectancy of ESRD patients Increasing access of younger people in countries in which RRT has been limited until today 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 DEVELOPING COUNTRIES DEVELOPED COUNTRIES 0 1000 2000 3000 4000 5000 19902020 Yusuf et al., Circulation, 2001 Deaths (x 1000) (1990 to 2020)

36. 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.) 11.251.52.02.50.5 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

37. World 2000 2030 154 m 370 m 55 m 84 m DevelopedDeveloping 99 m 286 m 16.7 33.8 32.9 18.2 52.4 30.7 28.3 9.1 80.9 22.8 42.3 18.6 0.91.6 2000 2030 * In million subjects 102% 81% 71% 211% 255% 127% 78% THE GLOBAL BURDEN OF DIABETES (2000-2030) WHO, March 2003

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

39. Lysaght et al., J Am Soc Nephrol, 2002 1200 600 0 Ten year medical costs of dialysis population $ ( billions) 1981-19901991-20002001-2010 800 1000 $ $ $ PREDICTED DIALYSIS COST OF APPROXIMATELY $ 1.1 TRILLION FOR THE COMING DECADE 400 200

40. 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 1.8 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

41. Cost of RRT Hemodialysis Hemodialysis $ 40,000 - 60,000 $ 40,000 - 60,000 Peritoneal dialysis Peritoneal dialysis $ 20,000 $ 20,000 Renal transplantation Renal transplantation $15,000 (first year) $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 DevelopedDeveloping Population, billions 0.934.9 Urban, %7431 Life expectancy, years7862 Birth rate1432 Infant mortality rate1377 GNP per capita, US$25,7001230 Kher, KI 2002

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

45. In Central Estern Europe during the period 1990-1996 there has been In Central Estern Europe during the period 1990-1996 there has been 56% increase of dialysis center 56% increase of dialysis center 78% of hemodialysis patients 78% of hemodialysis patients 306% of peritoneal dialysis patients 306% of peritoneal dialysis patients However the prevalence and incidence of RRT is significant lower than in European Union However the prevalence and incidence of RRT is significant lower than in European Union

46. 0 5000 10000 15000 20000 25000 30000 02004006008001000 Prevalence RRT pmp GNP ($ per capita) East Europe countries NATIONS DELIVER CARE FOR ESRD AS A FUNCTION OF THEIR ECONOMY EU countries

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

50. MUCH LESS IS KNOWN ABOUT THE INCIDENCE AND PREVALENCE OF CHRONIC KIDNEY DISEASE IN PRE-DIALYSIS PHASE StageEst.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 Third National Health And Nutrition Examination Survey (NHANES III) Estimate among US population

51. Event though it does not rank at the highest places, the global burden of Chronic Kidney Disease is significant and is probably underestimated Event though it does not rank at the highest places, the global burden of Chronic Kidney Disease is significant and is probably underestimated

52. 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 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

53. 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 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