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 Asians21 Europeans14 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

were pleased that kidney disease was uncommon

6Lysaght, MJ. JASN 2002; 13: S37

1990 2000 2010

426,000

1,490,000

2,500,000

ESRD is increasingly common worldwide

GLOBAL TREATMENT FOR ESRD

Moeller S et al. NDT 2002;17:2071

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

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

USRDS 2012 ADR

Geographic variations in the prevalence of ESRD, 2010

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

White et al, Bulletin WHO, March 2008

Prevalent patients on RRT and GDP per capita2002

Outcome of chronic HD in NigeriaMortality

< 1 mth 1-3 mths 3-6 mths 6-9 mths 9-12 mths

Percent mortality

Reasons for stopping dialysis in Nigeria

Ulasi, Ijoma J Trop Med, 2010, 50:1957

‘BRIC’ COUNTRIES

BrazilRussiaIndiaChina

RRT in Mainland China

HD PD TRANSPLANTATION

20-30%

104,671

134,59117,280

22,0005,500

127,451

162,090

Prevalence of RRT in some Asian countries

香港 2003

香港 2004

香港 2005

香港 2006

香港 2007

台湾 2003

台湾 2004

台湾 2005

台湾 2006

台湾 2007

日本 2003

日本 2004

日本 2005

日本 2006

日本 2007

878 928 970 1002 1027

19001999

21202219

17971852 1882

19562060(pmp)

HK JapanTaiwan

Prevalence of RRT in some Asian countries

香港 2003

香港 2004

香港 2005

香港 2006

香港 2007

台湾 2003

台湾 2004

台湾 2005

台湾 2006

台湾 2007

日本 2003

日本 2004

日本 2005

日本 2006

日本 2007

878 928 970 1002 1027

19001999

21202219

17971852 1882

19562060(pmp)

HK Japan

1 2 3 4 5 6 7 8

中国大陆03 04 05 06 07 08 09 10

33 37 40 45 53 66 83 116

Taiwan Mainland China

What drives increases in RRT ?

Economic growth

Healthcare systems

Commercial influence

Population expectation

Physician reimbursement

DEVELOPING ECONOMIESBRIC COUNTRIES

Brazil - Russia - India - China

Diligence is needed if the rapid growth of dialysis

in some developing countries isto proceed to the highest ethical standards

ETHICAL DIALYSIS

It is the responsibility of the global nephrology community

to set the standards

Diligence is needed if the rapid growth of dialysis

in some developing countries isto proceed to the highest ethical standards

ETHICAL DIALYSIS

Task Force on Ethical Standards in Dialysis2013

USRDS 2012 ADR

Comparison of unadjusted ESRD prevalence worldwide

All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.

USRDS 2012 ADR

How do we interpret such growth yet variablity ?

Success?

Failure?

Good care?

‘Rationing’ ?

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.

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

African Caribbeans

Hispanics

Native Americans

Why are White Caucasians protected from Type 2 diabetes & ESRD ?

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’

The Fellowship Program

RENAL DISASTER RELIEF TASK FORCE

USRDS 2012 ADR

Comparison of unadjusted ESRD incidence worldwide

USRDS 2012 ADR

The tide can be turned

KIDNEY TRANSPLANTATIONThe underused option

Deceased and living donor

Cost effective

Affordable in some countries where dialysis is not

KIDNEY TRANSPLANTATIONThe underused option

Deceased and living donor

Cost effective

Affordable in some countries where dialysis is not

BUT Cultural influences

Commercial pressuresExploitation

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

Low income countries

Lower middle income countries

Bolivia - Moldova

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

Cardiovascular disease

Diabetes

Chronic Kidney Disease – A VASCULAR DISEASE ?

Entry to ‘mainstream’ NCD policy

A ‘seat at the table’

We can discuss large populations at risk

A change of message

CKD just a minor issue… the ‘big boys’ do not want

a CKD diversion:

“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

CKD as a vascular disease ….. but NOT ONLY a vascular disease

United States

28% of those with CKD do not have hypertension, or diabetesUSRDS

CKD as a vascular disease ….. but NOT ONLY a vascular disease

United States

28% of those with CKD do not have hypertension, or diabetesUSRDS

China – Mongolia - Nepal

43% of those with CKD do not have cardiovascular disease, hypertension, or diabetes

Sharma SK et al. AJKD 2010; 56: 915

Up to ~40% of those with CKD do not have

cardiovascular disease, hypertension, or diabetes

Communicable disease

Glomerulonephritis

Hereditary/congenital diseases

Stones

Environmental factors

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

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

NOT Aristolochic acid

Growing evidence of

Heavy metal intoxication – cadmium, arsenic

in food, tobacco, soil, agrochemicals

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

Not aristolichic acid

Not heavy metals

Costa Rica, El Salvador, NicaraguaInterstitial disease

Less at higher altitudesSugar cane workers

? adverse effects ofrecurrent 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

What may these ’epidemics’ tell us about

apparently sporadic cases of

chronic kidney disease of uncertain cause ?

Every ‘epidemic’ is a different detective story

Each ‘epidemic’ is a new opportunity

Genetic ? Environment ?

SUSCEPTIBILITY TO KIDNEY DISEASE or PROGRESSION OF KIDNEY DISEASE

Fetal environment?

Genetic ? Environment ?

SUSCEPTIBILITY TO KIDNEY DISEASE or PROGRESSION OF KIDNEY DISEASE

Fetal environment?

BIRTHWEIGHT AND PROTEINURIA IN AUSTRALIAN ABORIGINALS

25% of Aborigines have birthweight < 2500gm

Hoy 2000 NDT;15:1293

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 RENAL DISEASE IN DEPRIVED POPULATIONS

ACUTE KIDNEY INJURY WORLDWIDE

Very limited epidemiological data

SepsisCritical care

Vascular disease

HOW DOES AKI DIFFER IN THE DEVELOPING WORLD ?

Communicable Disease

HOW DOES AKI DIFFER IN THE DEVELOPING WORLD ?

Obstetric complications

SepsisCritical care

Vascular disease

PREVENTION OF AKI

SepsisCritical care

Vascular disease

• Clean water• Malaria control• HIV control• Immunisations

• Maternity care

TREATMENT OF AKI IN THE DEVELOPING WORLD

Treatment including acute dialysis (usually PD)• saves young lives• is cost effective

• gives major health gain

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 OECD countriesPHYSICIANS WHO HAVE LEFT THEIR HOME COUNTRY

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 NEPHROLOGISTSIN INDIA ?

The attractions of private hospitals

The challenge for academic medicine

ISN FELLOWSHIP PROGRAMMELow & 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

USRDS 2012 ADR

The tide can be turned

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

M Tonelli S Agarwal A Cass G Garcia Garcia V Jha

S Naicker HY Wang C-W Yang D O’Donoghue

ISN CKD Policy Task Force (2013)

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 ONNON-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

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

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 countriesand that these diseases share common risk factors

and can benefit from common responses to non-communicable diseases”.

Paragraph 19:

One small step …….

Paragraph 19:

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 waterMalaria control

HIV controlImmunisations

Maternity care

FUTURE PREVALENCE OF KIDNEY DISEASE

Interventions to control or reduce obesity

…. will eventually help to reduce the incidence of CKD

Implications for health policy

PREVALENCE OF CKD IN DISADVANTAGED POPULATIONS

Fall in perinatal mortality will increase survival of low birthweight babies

Adults will survive longer to get CKD

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

GLOBAL NEPHROLOGY

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