BURDEN OF DIALYSIS INITIATION AND C - KDIGO

GLOBALBURDENOFDIALYSISINITIATION

(ANDCONTINUATION)

VivekJhaGeorgeInsAtuteforGlobalHealthIndia

Disclosure of Interests

Employment

• George Institute for Global Health

Grants

• Baxter Healthcare, GSK

Consultancy

• NephroPlus, Baxter Healthcare

KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription January 25-28, 2018 | Madrid, Spain

This is how it started


CARI Guidelines

Availability of resources should not be a reason to

deny a patient access onto dialysis.

Decisions to recommend or not to recommend dialysis should not be influenced by either availability

of resources or potential litigation.


2017 Annual Data Report Volume 2 ESRD, Chapter 11

IncidencerateoftreatedESRD(pmp),2015

Datasource:Specialanalyses,USRDSESRDDatabase.Datapresentedonlyforcountriesfromwhichrelevantinforma>onwasavailable.Allratesareunadjusted.ÛnitedKingdom:England,Wales,NorthernIreland(Scotlanddatareportedseparately).DataforItalyincludefiveregions.DataforIndonesiarepresenttheWestJavaregion.DataforFranceexcludeMar>nique.DataforCanadaexcludesQuebec.Japanincludesdialysispa>entsonly.DataforLatviarepresents80%ofthecountry’spopula>on.Abbrevia>ons:ESRD,end-stagerenaldisease;sp.,speaking.NOTE:Datacollec>onmethodsvaryacrosscountries,sugges>ngcau>oninmakingdirectcomparisons.


PrevalenceoftreatedESRDpermillionpopulaAon,bycountry,2015

Datasource:Specialanalyses,USRDSESRDDatabase.Datapresentedonlyforcountriesfromwhichrelevantinforma>onwasavailable.ÛnitedKingdom:England,Wales,NorthernIreland(Scotlanddatareportedseparately).Theprevalenceisunadjustedandreflectsprevalenceattheendof2015.Switzerlandincludesdialysispa>entsonly.DataforIndonesiarepresenttheWestJavaregion.DataforFranceexcludeMar>nique.DataforItalyincludesfiveregions.DataforCanadaexcludesQuebec.DataforLatviarepresents80%ofcountry’spopula>on.Abbrevia>ons:ESRD,end-stagerenaldisease;sp.,speaking.NOTE:Datacollec>onmethodsvaryacrosscountries,sugges>ngcau>oninmakingdirectcomparisons.


TrendsintheincidencerateoftreatedESRD(pmp),2002-2015

(a)TencountrieshavingthehighestpercentageriseinESRDincidenceratein2002/03versusthatin2014/15,plustheU.S.

Datasource:Specialanalyses,USRDSESRDDatabase.Allratesareunadjusted.DatafortheCzechRepublicaremissingfrom2012indicatedbythedashedline.DataforU.S.areshownforcomparisonpurposes.Abbrevia>on:ESRD,end-stagerenaldisease.NOTE:Datacollec>onmethodsvaryacrosscountries,sugges>ngcau>oninmakingdirectcomparisons.


TrendsintheincidencerateoftreatedESRD(pmp),2002-2015

Datasource:Specialanalyses,USRDSESRDDatabase.Allratesareunadjusted.Onlysixcountrieshadadecreaseinincidencefrom2002/03-2014/15.Abbrevia>on:ESRD,end-stagerenaldisease.NOTE:Datacollec>onmethodsvaryacrosscountries,sugges>ngcau>oninmakingdirectcomparisons.

(b)SixcountrieshavingthelargestpercentagedeclineinESRDincidencerate:2002/03versusthatin2014/15


PercentagechangeinthestandardizedincidencerateofESRDintheU.S.populaAon,1980-2015

DataSource:ReferenceTableA.2(2)andspecialanalyses,USRDSESRDDatabase.Standardizedforage,sex,andrace.Thestandardpopula>onwastheU.S.popula>onin2011.Abbrevia>on:ESRD,end-stagerenaldisease.

(b)One-yearpercentagechangeinstandardizedincidencerate


IncidencerateoftreatedESRD(pmp),bysexandcountry,2015

Datasource:Specialanalyses,USRDSESRDDatabase.Datapresentedonlyforcountriesfromwhichrelevantinforma>onwasavailable.ÛnitedKingdom:England,Wales,NorthernIreland(Scotlanddatareportedseparately).DataforFranceexcludeMar>nique.DataforIndonesiarepresenttheWestJavaregion.DataforItalyrepresentfiveregions.DataforCanadaexcludesQuebec.Japanincludesdialysispa>entsonly.DataforLatviarepresents80%ofcountry’spopula>on.Abbrevia>ons:ESRD,end-stagerenaldisease;sp.,speaking.NOTE:Datacollec>onmethodsvaryacrosscountries,sugges>ngcau>oninmakingdirectcomparisons.

Worldwide Dialysis Population

90%

<50.0

100.0-499.9 500.0-999.9 1000.0-1999.9 ≥2000.0

Prevalence of patients received RRT (pmp)

50.0-99.9

No available data

123 countries for which the prevalence data could be obtained


Prevalence of hypertension or diabetes and prevalence of patients on dialysis in 123 countries.

Prevalence of dialysis (pmp)=exp(-9.540+ 0.150*prevalence of diabetes [%, p=0.21])*106

5 10 15 20

Prevalence of diabetes (%)

0.1

1

10

100

1,000

10,000

Pre

vale

nce

of d

ialy

sis

(pm

p)

Prevalence of dialysis (pmp)=exp(-9.576+ 0.039*prevalence of hypertension [%, p=0.42])*106

25 30 35 40 45 50 55

Prevalence of hypertension (%)

0.1

1

10

100

1,000

10,000

Pre

vale

nce

of d

ialy

sis

(pm

p)

Hypertension：BP ≥ 140/90 mmHg and/or use of antihypertensive agents

Diabetes：Fasting glucose level ≥ 7.0 mmol/L and/or use of glucose-lowering agents

Prevalence of hypertension Prevalence of diabetes


Prevalence of dialysis (pmp)=exp(-22.374+ 0.193*Life expectancy [years, p<0.001])*106

0.1

1

10

100

1,000

10,000

Pre

vale

nce

of d

ialy

sis

(pm

p)

50 60 70 80 90 Life expectancy at birth (years)

*Median age and life expectancy at birth were strongly correlated each other (r=0.78, p<0.001). The model including life expectancy at birth was more fitted than the model including median age of population.

Life expectancy at birth or GNI per capita and prevalence of patients on dialysis in 123 countries

Gross national income per capita (US$)

Prevalence of dialysis (pmp)=exp(-15.248+ 0.797*Log (GNI) [US$, p<0.001])*106

300 1,000 3,000 10,000 30,000 100,000 0.1

1

10

100

1,000

10,000

Pre

vale

nce

of d

ialy

sis

(pm

p)

Life expectancy at birth GNI per capita


Gonzalez-Bedat et al, Clin Nephrol 2015

Association between age and prevalence of patients on dialysis in 20 high-income countries with available age-

specific data

Age (years)

Data from mainly European and Oceania countries (from 16 countriesa) )

Data from USA, Japan, Taiwan and Singapore

Prevalence of RRT (pmp)= exp(-8.80+0.04*Age [years, p<0.001])*106

Prevalence of RRT (pmp)= exp(-8.49+0.05*Age [years, p<0.001])*106

0

2,000

4,000

6,000

8,000

10,000

12,000

0 10 20 30 40 50 60 70 80

Pre

vale

nce

of R

RT

(pm

p)

a) Data from Australia, New Zealand, Austria, Belgium, Denmark, Finland, France, Greece, Iceland, Norway, Spain, Sweden, the Netherlands, United Kingdom, Canada and Saudi Arabia

<50.0

100.0-499.9 500.0-999.9 1000.0-1999.9 ≥2000.0

Prevalence of patients received RRT (pmp)

50.0-99.9

Estimated value

Global number of patients on dialysis in 2010 = 2.62 million

(Number of Dialysis: 2.05 million [78%]) *99% of these numbers were based on the actual data from 123 countries.

Global number of patients who received dialysis in 2010

Lityanange et al Lancet 2013

Prevalence of patients who received RRT and their numbers according to regions

Population (x billion)

Num

ber o

f RR

T ( x

mill

ion)

0

0.5

1.0

1.5

0.08

0.97

0.53

0.37

0.64

0.03

(1.03) (4.17) (0.74) (0.60) (0.35) (0.04)

Africa Asia Europe Latin America

North America Oceania

Regions

Population (x billion)

0

500

1,000

1,500

2,000

Pre

vale

nce

of R

RT

(pm

p)

80 232

719 626

1,840

695

(1.03) (4.17) (0.74) (0.60) (0.35) (0.04)

Africa Asia Europe Latin America

North America Oceania

Regions KDIGO Controversies Conference on Dialysis Initiation, Modality Choice & Prescription

January 25-28, 2018 | Madrid, Spain Lityanange et al Lancet 2013

Prevalence of patients who received RRT and their numbers according to World Bank income groups

World Low Lower- middle

High

0

500

1,000

1,500

2,000

Pre

vale

nce

of R

RT

(pm

p)

379

1,473

318

69 20

Upper- middle

(6.92) (0.79) (2.50) (2.52) (1.11) Population (x billion)

Income groups

World

Num

ber o

f RR

T ( x

mill

ion)

0

0.5

1.0

1.5

2.0

2.5

3.0 2.62

High 1.63 (62.1%)

Upper- middle

0.80 (30.7%)

Low 0.02

(0.6%) Lower- middle

0.17 (6.6%)

Income groups

Income groups GNI per Capita (US$) Low: ≤$1,005 Lower-middle: $1,006-$3,975 Upper-middle: $3,976-$12,275 High: ≥$12,276 Lityanange et al Lancet 2013

Difference between numbers of people on and those who need RRT

World

Prevalence of people received RRT

Prevalence of people possibly requiring RRT estimated by the model based on the data from high income countries of mainly European and Oceania countries

Population (x million) (6,915)

Num

ber o

f pat

ient

s ( x

mill

ion)

2.62

4.90

-47%

0

1.0

2.0

3.0

4.0

5.0

6.0

(1,031)

Africa (4,165)

Asia (740)

Europe (596) Latin

America

(346) North

America

(36)

Oceania

0.08

0.51

-84% 0.97

2.88

-66%

0.53 0.76

-30%

0.37 0.40

-7% 0.64

0.32

+97%

0.030.03

-16%

Regions Liyanage et al Lancet 2015

Difference between numbers of RRT and ESKD worldwide and by income levels

World Low income Lower-middle Upper-middle High income

Prevalence of RRT Prevalence of ESKD estimated by the conservatively-estimated model Prevalence of ESKD estimated by the high-estimated model

Population (x million) (6,915) (793) (2,496) (2,520) (1,105)

Income levels

Num

ber o

f pat

ient

s ( x

mill

ion)

-73%

0

2.0

4.0

6.0

8.0

10.0

2.62

4.90

9.70

-47%

0.02 0.41 0.76

-96%

-98%

0.17

1.49

2.83 -88%

-94%

0.80

1.90

3.78

-58%

-79%

1.63 1.11

2.33 +47%

-30%

12.0

Africa (0.08→0.24)

Asia (0.97→2.16)

Europe (0.53→0.83)

Latin America (0.37→0.90)

North America (0.64→1.26)

Oceania (0.03→0.05)

World

Num

ber o

f RR

T (x

mill

ion)

0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

Year 2010 2015 2020 2025 2030

Year 2010 2015 2020 2025 2030

0.0

1.0

2.0

3.0

Num

ber o

f RR

T (x

mill

ion)

Region

Trend in the estimated number of dialysis patients

2.62 3.13

3.78

4.53

5.44

Lityanange et al Lancet 2013

Prosperity and access to dialysis

Jha et al Lancet 2013

Economic impact of ESRD treatment

Ramachandran and Jha, PLOS One 2013

2018 2023

1400 -1500 pmp

1900 -2000 pmp

1073 pmp

2013

Courtesy: Kriang Tungsanga

What happens when financial barrier is removed?

What happens when the financial barrier is removed?

30

41 47

70

30

54

89

120

0

20

40

60

80

100

120

140

2008-09 2009-10 2010-11 2011-12

Num

ber p

er m

illio

n of

the

popu

latio

n

Annual incidence No. dialysed in the year

Shaikh M, et al (submitted)

Survival on HD (2008-12, n=13,118)


Survival on HD (2008-12, n=13,118)


Patient outcomes (2008-12, n=13,118)

Continuing HD, 2,259, 17%

Transplanted, 296, 2%

Dead, 2,237, 17%

Stopped HD, 8,326, 64%


Blagg CR, Hemodial Int 2012

Rationing practices


9 November 1989

DialysisaccessisrelatedtopoliAcalsituaAon

Change in incidence of RRT in central and eastern Europe (2001, 2004)

0 20 40 60 80

100 120 140 160 180

Rutkowski, Ethn Dis 2009

Factors that impact dialysis initiation

•  GDP per capita •  Percentage of GDP spent on health care •  Dialysis reimbursement rate •  Private for-profit share of dialysis

provision •  Fragmentation of healthcare services •  Renal unit distribution •  Workforce availability


Factors that affect numbers on dialysis

•  Expanding insurance coverage •  Presence of CKD care plan •  Rationing policies •  Choice of dialysis modality (HD v PD) •  Incremental dialysis •  Advance care planning


Global Dialysis burden

All ESRD

Recognized

Access RRT

Stay on RRT

Data/registries Financing

Workforce Governance and policy

Gaps in dialysis initiation


Conclusions

•  There is a large (and increasing) unmet global need of dialysis

•  Determinants of dialysis initiation are largely non-medical

•  Removal of financial barrier increases uptake/initiation on dialysis

•  Insurance coverage does not remove all barriers to long-term care

•  Residual inequities around dialysis initiation need addressing


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BURDEN OF DIALYSIS INITIATION AND C - KDIGO