European Parliament Symposium - Era-Edta · European Parliament Symposium. European Kidney Health...

Chronic Kidney Disease and Chronic Kidney Disease and

Hypertension Hypertension

Twin Challenges for 21st Century EuropeTwin Challenges for 21st Century EuropeEuropean Parliament, 10th March 2009European Parliament, 10th March 2009

European Parliament European Parliament

SymposiumSymposium

European Kidney Health European Kidney Health

Alliance (EKHA)Alliance (EKHA)

Alliance of notAlliance of not--forfor--profit organizations profit organizations

who represent the key stakeholders in who represent the key stakeholders in

kidney health issues in Europekidney health issues in Europe

CEAPIR CEAPIR ERAERA--EDTAEDTA

EDTNA/ERCA EDTNA/ERCA IFKFIFKF

EKHA EKHA –– unique alliance unique alliance

A single voice representing the A single voice representing the

combined views of the renal combined views of the renal

communitycommunity

Kidney disease is more Kidney disease is more

than kidney failurethan kidney failure

Around 250,000 people are being Around 250,000 people are being

treated for kidney failure in the EU27treated for kidney failure in the EU27

butbut

Chronic kidney disease affects at least Chronic kidney disease affects at least

10% of the population 10% of the population –– 40 million 40 million

people people

What is chronic kidney What is chronic kidney

disease ?disease ?

�� CKD is the generic name for persistent CKD is the generic name for persistent kidney damage regardless of causekidney damage regardless of cause

�� CKD is commonly caused by high blood CKD is commonly caused by high blood pressure, diabetes or renal inflammationpressure, diabetes or renal inflammation

�� CKD is graded into five stages depending on CKD is graded into five stages depending on the degree of kidney functional impairment the degree of kidney functional impairment

�� CKD Stage 5 requires treatment with CKD Stage 5 requires treatment with dialysis or kidney transplantation dialysis or kidney transplantation

CKD CKD –– the silent epidemicthe silent epidemic

Most patients with CKD feel entirely well Most patients with CKD feel entirely well

but have greatly increased risk of but have greatly increased risk of --

Progressive kidney failureProgressive kidney failure

Cardiovascular disease Cardiovascular disease

CKD and Hypertension: CKD and Hypertension:

silent partnerssilent partners

Chronic kidneydisease

Hypertension

Progressive Kidney failureHeart attacksStrokes

The need for greater awareness of CKD

Lack of awareness:– 73% of those being treated for hypertension were ignorant of their risk of developing CKD

– 47% had had their kidney function assessed

– 18% had discussed steps to help look after their kidneys with their doctor

– 11% are aware that there are no obvious symptoms of early-stage CKD

Based on a survey of 286 individuals with cardiovascular disease in Europe – TNS 2009

EKHA EKHA –– fundamental fundamental

objectivesobjectives

�� Raising awareness of kidney diseaseRaising awareness of kidney disease

�� Promoting uniform standards of carePromoting uniform standards of care

�� Supporting research and developmentSupporting research and development

�� Cooperating with EU Cooperating with EU organisationsorganisations

�� Facilitating exchange of informationFacilitating exchange of information

EKHA EKHA –– Engaging the EUEngaging the EU

First year First year -- Establishing linksEstablishing links

DG Research DG Research –– lobbied for research in CKDlobbied for research in CKD

DG SANCO DG SANCO –– lobbied for renal programslobbied for renal programs

EU ParliamentEU Parliament --Amendment on CKD prevention in Amendment on CKD prevention in Resolution on Organ Donation and TransplantationResolution on Organ Donation and Transplantation

Second year Second year -- Strengthening linksStrengthening links

EU Parliament EU Parliament --Public health programs to reduce Public health programs to reduce the need for renal transplants as part of Action Plan the need for renal transplants as part of Action Plan and Directive on Organ Donation and and Directive on Organ Donation and Transplantation Transplantation

EKHA

www.ekha.eu

Chronic Kidney Disease and Hypertension -Twin chall enges for 21st century Europe

World World Health Health

OrganizationOrganization

CancerCancer --lymphomalymphoma

CardiovascularCardiovascular

CKDCKD

A MUCH SILENT EPIDEMICSA MUCH SILENT EPIDEMICS

CKDCKD……stillstill notnot mentionedmentioned amongamong ChronicChronic diseasesdiseases bybythe the WHOWHO…… ……....

Old ageOld age

infectious diseasesinfectious diseases

MortalityMortality

1800 1800 1900 1950 1980 20001900 1950 1980 2000epidemiologic epidemiologic transitiontransition

The The ascendancyascendancy of of cardiovascularcardiovascular diseasedisease

50

75

Life durationLife duration

1900 20001900 2000

High LDL & High LDL & low HDL Cholesterollow HDL Cholesterol

HypertriglyceridemiaHypertriglyceridemia

Fasting hyperglicemiaFasting hyperglicemia

*

...and.......and....

CKDCKD%%1818

1616

1414NHANES IIINHANES III

19881988--9494NHANES IVNHANES IV19991999--20042004

14.5%

16.8%

after 10 years

CardiovascularCardiovascularCKDCKD

XXXXthth Century ICentury I stst epidemics waveepidemics waveTrade off: Trade off: 22ndnd epidemics waveepidemics wave

HugeHuge investmentsinvestments in in preventionprevention of CV of CV diseasesdiseases

XXthXXth Century Century RiskRisk FactorsFactors ((FraminghamFramingham RiskRisk FactorsFactors ))

LongerLonger life life expectancyexpectancy ofofpoeplepoeple withwith CV CV diseasesdiseases

GFR

The Chronic Kidney Disease Epidemics by stagesThe Chronic Kidney Disease Epidemics by stages

NHANES III survey & USRDSNHANES III survey & USRDS

ModerateModerateSevereSevere ESRDESRD

dialysisdialysisMillionsMillions

100100

8080

6060

4040

2020

000.2%0.2%

~~0.5 million0.5 million

0.2%0.2%0.5 million0.5 million

4.3%4.3%7.6 millions7.6 millions

...Florence...Florence

...Eindhoven...Eindhoven

...Lyon...Lyon

MildMild

Frank diabetesFrank diabetesHypertriglyceridemiaHypertriglyceridemialow HDL Cholesterollow HDL Cholesterolfasting hyperglycemiafasting hyperglycemia

The The figuresfigures of of riskrisk factorsfactorsnownow and in the and in the foreasebleforeaseble futurefuture

BillionsBillions3.03.0

2.52.5

2.02.0

1.01.0

0.50.5

00

1960 1985 2002 2017 20301960 1985 2002 2017 2030

BillionsBillions3.03.0

2.52.5

2.02.0

1.01.0

0.50.5

00

1.321.32

1.61.6

0.120.120.4000.400

2010

Europe

Hypertension by 2025

Africa

North America

%100806040200

+24%

+80%

S.America(some countries )

Risk factors geography

Diabetes in 2010

Africa19 millions

North America19 millions

GFR GFR (ml) (ml) 9090--60 6060 60--3030DysfunctionDysfunction MildMild ModerateModerate

%%5050

4040

3030

2020

1010

00

DS Keith, JAMA 164: 659, 2004DS Keith, JAMA 164: 659, 2004

1%1% 1%1%ESRD / ESRD / dialysisdialysis

19%19%

24%24%

MortalityMortality

The The truetrue riskrisk of CKD of CKD isis more more heartheart diseasedisease thanthan ESRD ESRD

The Chronic Kidney Disease EpidemicsThe Chronic Kidney Disease Epidemics

Groningen HollandGroningen Holland85.000 residents 2885.000 residents 28--75 yrs.75 yrs.

GroningenGroningen

Courtesy dr. P.De JongCourtesy dr. P.De Jongmean age: 49 yearsmean age: 49 years

GFR

The Chronic Kidney Disease EpidemicsThe Chronic Kidney Disease Epidemics

NHANES III surveyNHANES III surveyMean age Mean age ∼∼45 years45 years

ModerateModerateSevereSevere ESRDESRD

%%6060

4040

3030

2020

1010

00 0.2%0.2%0.2%0.2%4.3%4.3% 4.9%4.9%

0.1%0.1% 0.1%0.1%

%%1515

1010

55

00

malesmales

Moderate Moderate totoSevere Severe RenalRenalInsufficiencyInsufficiency

((all all agesages ))

%%1515

1010

55

00

femalesfemales

EnglandEngland

BelgiumBelgium

NorwayNorway

IcelandIceland

ItalyItaly

GermanyGermany BelgiumBelgium

GermanyGermany

NorwayNorwayItalyItaly

EnglandEnglandIcelandIceland

8%8%

4%4%

11%11%

6%6%

20 March 200920 March 2009

a strong a strong messagemessage shouldshould bebe delivereddelivered toto EU EU countriescountries, the WKD , the WKD messagemessage....

CKD CKD isis common and common and harmfulharmful……butbut alsoalso preventablepreventable and and treatabletreatable

Zoccali C, Jager K, Kramer A. Zoccali C, Jager K, Kramer A. EuglorehEugloreh report 2009report 2009

Because of the ageing world population and conseque nt Because of the ageing world population and conseque nt increasingincreasing prevalence of hypertension and diabetes, CKD prevalence of hypertension and diabetes, CKD rates will continuerates will continue to increase to increase

Focus on public awareness and screening Focus on public awareness and screening programmesprogrammes as as well as well as programmesprogrammes to educate both patients and physicians to educate both patients and physicians is fundamental. is fundamental.

Screening for risk factors of CKD like hypertension and Screening for risk factors of CKD like hypertension and diabetes and combating obesity is fundamental for halting diabetes and combating obesity is fundamental for halting the CKD epidemics. the CKD epidemics.

S S && C C

Public Health Strategies to address Public Health Strategies to address

CKD and its associated diseasesCKD and its associated diseases

Tom Oostrom Tom Oostrom M.Sc.M.Sc.

Vice President Dutch Kidney FoundationVice President Dutch Kidney Foundation


SymposiumSymposium

Dutch perspectiveDutch perspective


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1.1. Positioning a health foundationPositioning a health foundation

2.2. Example public health strategy: Kidney Check and Example public health strategy: Kidney Check and

Prevention ConsultPrevention Consult

3.3. Hurdles in the Dutch health care systemHurdles in the Dutch health care system

4.4. Input for public health strategies in EuropeInput for public health strategies in Europe


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SymposiumSymposium

Professionals

Patients

Insurance companies/ government

Positioning a Positioning a

health foundationhealth foundation

Background Kidney checkBackground Kidney check

-- 1 in 200 have kidney damage1 in 200 have kidney damage

-- Diabetes/hypertension: Diabetes/hypertension:

GPGP’’s screen in only 10s screen in only 10--40% 40%

of the cases on albuminuriaof the cases on albuminuria


SymposiumSymposium

Goals Kidney checkGoals Kidney check

-- Detection kidney damage at an Detection kidney damage at an

early stageearly stage

-- Create awareness among GPCreate awareness among GP’’s s

about importance of early about importance of early

detection detection


SymposiumSymposium

Results Kidney checkResults Kidney check

-- 1.1 million Kidney Checks 1.1 million Kidney Checks

requested (8,7% population 18+)requested (8,7% population 18+)

-- 170 kidney disease, 2.700 170 kidney disease, 2.700

albuminuria, 270 diabetes, 1.400 albuminuria, 270 diabetes, 1.400

hypertension. Total found 4.500hypertension. Total found 4.500


SymposiumSymposium

Next steps?Next steps?

-- We started a prevention program with Heart and We started a prevention program with Heart and DiabetesDiabetes Foundations: Foundations: ‘‘Live a long and healthy lifeLive a long and healthy life’’(LekkerLangLeven) (LekkerLangLeven) �� one checkone check

-- Contact with The Dutch College of General Practitioners Contact with The Dutch College of General Practitioners (NHG) about collaboration on a health check used by (NHG) about collaboration on a health check used by GPGP’’s: Prevention Consults: Prevention Consult


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Lessons Lessons

-- Let health funds play the role of innovator and initiator in Let health funds play the role of innovator and initiator in

breaking down walls; in this case it had effectbreaking down walls; in this case it had effect

-- Involve the GPInvolve the GP’’s in your plans, it helps acceptation and s in your plans, it helps acceptation and

implementationimplementation

-- DonDon’’t act alone as renal communityt act alone as renal community


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A A succesfullsuccesfull story? Still problemsstory? Still problems


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carecure

preventioncare

relatedindicativeselectiveuniversal



SymposiumSymposium

carecure

preventioncare


Law onPH

Laws on individual health care



SymposiumSymposium

carecure

preventioncare


Law onPH


Govern-ment

Insurance companies



SymposiumSymposium

carecure

preventioncare


Law onPH

Govern-ment

Insurance companies

Early detection of the population at risk?


Lobby needed to get early detection covered, but:Lobby needed to get early detection covered, but:

1.1. Public health is fragmented, members act apartPublic health is fragmented, members act apart

2.2. Relatively limited budget for public health research Relatively limited budget for public health research

3.3. Research is a condition for evidence based prevention Research is a condition for evidence based prevention

interventionsinterventions


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Work to do:Work to do:

Organize the public health communityOrganize the public health community

Lobby with one voiceLobby with one voice

More impact on research agenda (PH oriented)More impact on research agenda (PH oriented)

More evidence based interventions condition for More evidence based interventions condition for

coverage by insurance companies (closing gap)coverage by insurance companies (closing gap)


SymposiumSymposium

Recommendations:Recommendations:1.1. Let health foundations enforce changeLet health foundations enforce change

2.2. DonDon’’t act alone as renal community (WKD/WHD t act alone as renal community (WKD/WHD

good example)good example)

3.3. Organize the public health community locally and in Organize the public health community locally and in

Europe (public health is a shared concern)Europe (public health is a shared concern)

4.4. Focus lobby on the research agendaFocus lobby on the research agenda

5.5. More PH means more manpowerMore PH means more manpower


SymposiumSymposium

Impossible?Impossible?

Not if we go for it, Not if we go for it,

together!together!


SymposiumSymposium

Valerie TwomeyCork, Ireland

Before Transplantation• 2004: nephrologists confirmed ESRF - dialysis or transplantation essential

• Tired, pale skin, trouble concentrating, poor appetite, nauseated, swollen ankles & changes in urination

• Dialysis for two years to ensure optimum clearance achieved

– Home Dialysis – ‘Peritoneal Dialysis’

– Hospital based ‘Haemodialysis’

• Massive impact on the whole of my life, not just on my physical condition

– Lifestyle (eg 4am slot)

– Dietary & fluid restrictions

– Body image

– Social implications

– Work

– Financial implications

2

The Phone Finally Rings

• 4.45am – June 2006

“We have a fantastic Kidney for you – would you like to take it?”

• Mixed emotions – excitement, disbelief, fear, anxiety, sadness (deceased donor)

• Bag packed for two years - week before the call, decided to refresh my clothes

• 9.00am - arrived at Beaumont hospital:

– Physical examination – to check that it was safe to proceed

– The cross-match – a negative cross-match meant the operation could go ahead

• 2.30pm – wheeled down to surgery

• 8.30pm – back in the ward

3

• Rejected after 10 days - back on dialysis & received intravenous steroids for 5 days

• Took a year to recover following transplantation

• Less medications

• Longer life expectancy

• Freedom from dialysis and no diet/fluid restrictions

• Far more energy – a great quality of life

• Very determined advocate for Organ Donor Awareness, representing Ireland at the World Transplant Games August 2009

4

Life After Transplantation

The Way Forward

• Public health promotion – healthy lifestyle & healthy diet

• Better integration of care between GP’s & specialists

• Well disseminated treatment guidelines to all health professionals

• Research focused on understanding complications that accompany longer life span

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