Perspectivas Globales de la ERC en Poblaciones Vulnerables. Retos para los países en desarrollo .

1. APRIL 8,9 AND 10th, 2010 RESISTENCIA CITY - CHACO - ARGENTINA Perspectivas Globales de la ERC en Poblaciones Vulnerables. Retos para los países en desarrollo. Lawrence Agodoa, M.D. Director, Office of Minority Health Research Coordination, National Institute of Diabetes and Digestive and Kidney Diseases National Institutes of Health, Bethesda, Maryland, USA

2. ISN Mission Statement • The International Society of Nephrology (ISN) is dedicated to advancing the diagnosis, treatment, and prevention of kidney diseases in the developing and developed world.It will achieve this philanthropic mission through collaborations, meetings, publications, outreach, and other activities that: • Raise public awareness of the importance of early recognition and treatment of kidney diseases • Connect professionals interested in kidney and related diseases around the world • Support research to achieve optimal care of people with kidney diseases • Provide nephrology education and training worldwide; and ultimately • Reduce the frequency and impact of kidney diseases and their associated conditions.

3. Global Perspective of CKD in Disadvantaged PopulationsChallenges for Third World Countries.

4. Stages of CKD NHANES III Estimates (1988-94) Glomerular Filtration Rate, ml/min/1.73m2 Stage Kidney Failure (300,000) 5 <15 Severely Decreased Filtration (400,000) 4 15-29 30-59 Moderately Decreased Filtration (8 million) 3 60-89 Kidney Damage with Mildly Decreased Filtration (5 million) 2 Normal ~ 120 1 Kidney Damage with Normal Filtration (6 million) Am J Kid Dis 39:S1-S266, 2002

5. GFR NHANES – 1988-94 5 Kidney Failure (300,000) <15 4 Severely Decreased Filtration (400,000) 15-29 Moderately Decreased Filtration (8 million) 30-59 3 Kidney Damage with Mildly Decreased Filtration (5 million) 60-89 2 Kidney Damage with Normal Filtration (6 million) Normal ~ 120 1 Kidney damage = persistent microalbuminuria or proteinuria

6. Prevalence of CKD in NHANES participants, by CKD stage, age, gender, race/ethnicity, & severity of disease (percent of participants) NHANES participants age 20 & older; creatinine-based eGFR estimated by MDRD method, NHANES 1999–2002. *Estimate not reliable.

7. Percent of patients advancing to ESRD or dying during a two year follow-up, by DM and CKD status vs dialysis5% Medicare sample , 1996-1997 cohort (RR: Death vs ESRD) Follow-up: 12-31-1999 5.85 2.25 0.31 0.07 RR: 5.0 RR: 134 RR: 47 RR: 11 (Prev. 1997) Status in the entry period Kidney Int Suppl. 2003 Nov;(87):S24-31

8. Rates of Death and Cardiovascular Events in Patients According to GFR eGFR (mL/min/1.73 m2) N = 1,120,295 adults. *Age-standardized rates per 100 person-years; †Cardiovascular event defined as hospitalization for coronary heart disease, heart failure, ischemic stroke, and peripheral arterial disease per 100 person-years. Go et al. N Engl J Med. 2004;351:1296-1305.

9. Death versus ESRD in the recognized CKD population • Death is the dominant event in the CKD population. • ESRD rates are 1/5th to 1/50th of death rates in the various CKD populations. • CKD death rates are 3-4 times those of the non-CKD population, and about 50% of the rate in the dialysis population.

10. CKD/ESRD Prevalence Disparities Relative prevalence of stage 1 - 3 CKD Relative prevalence of ESRD * Ref Ref * *Compared to non-Hispanic whites Coresh J, et al. Am J Kidney Dis. 2003 Jan;41(1):1-12; USRDS 2003 Annual Data Report

11. Projected counts of incident & prevalent ESRD patients and deaths through 2020 Deaths

12. Adjusted incident rates & annual percent change Incident ESRD patients; rates adjusted for age, gender, & race.

13. Adjusted prevalent rates & annual percent change December 31 point prevalent ESRD patients; rates adjusted for age, gender, & race.

14. Incident counts & adjusted rates by race, ethnicity and cause of ESRD Incident ESRD patients; rates adjusted for age & gender.

15. Summary – ESRD in the USA • In 2007, the adjusted rate of new ESRD cases was 354 per million population. • The incidence rate of ESRD (especially diabetic ESRD) is trending downwards in Whites and Native Americans but continues to increase in African Americans • The rate of new ESRD cases among African Americans was 3.7 times greater than the rate among non-Hispanic whites. • Hispanics accounted for 13% of new ESRD patients in 2007. Their rate was 1.5 times greater than that of non-Hispanics. • In 2007, diabetes was the cause of ESRD in 54% of new patients; hypertension was the cause of ESRD in 33% of new patients. • The prevalent rate of ESRD among African Americans was 4.2 times greater than the rate among whites. • Racial and Ethnic Minorities have survival advantage over Caucasians once ESRD develops. This survival advantage is negated with successful transplantation.

16. Global Experience

17. ESRD Worldwide • Incidence increasing - 6 % every year. • Population growth rate - 1.2%. • Prevalence worldwide approx. 2,900,000. • Estimate 100-1500/million population. • 89% on hemodialysis. • 11% on CAPD. • >445,000 post transplants.

18. Number of patients worldwide treated with chronic dialysis from 1990 to 2010 2,500,000 1,490,000 426,000 1990 2010 2000 Lysaght, J Am Soc Nephrol, 2002

19. Comparison of ESRD incidence and Prevalence worldwide

20. Worldwide incident rates (per million population) Per million population; data represent the most current information available (primarily 2004). Incident data from Israel, Jalisco, Japan, Luxembourg, Pakistan, the Philippines, & Taiwan are dialysis only.

21. Worldwide incident rates (per million population) Per million population; data represent the most current information available (primarily 2004). Incident data from Israel, Jalisco, Japan, Luxembourg, Pakistan, the Philippines, & Taiwan are dialysis only.

22. Prevalence of ESRD world wide, 2007

23. Comparative ESRD Experience Worldwide

24. Africa Experience: ESRD Resource Availability.

25. ESRD & Dialysis Global Prevalence 2001 data Moeller S, Gioberge S, Brown G. NDT 2002;17:2071-2076

26. Global challenges: Risk factors for causes and progression of Chronic Kidney Disease • Non modifiable causes • Race • Ethnicity • Genetics • Gender • Age • Modifiable causes • Diabetes • Word wide increase 171 million in 2000 to 366 million in 2030 • Hypertension • Estimated to increase from 972 million in 2009 to 1.56 billion in 2025 • Obesity • Hyperlipidemia • Smoking • Poverty • Social Deprivation

27. WHO 2010

29. Global Prevalence of Hypertension Houssain et al: AJKD 53:166-174, 2009

30. World Income Distribution

31. Characteristics of Developing Countries that contribute to the development and progression of kidney disease • Countries located in Africa, Asia, Latin America and the Middle East. • 80% of world population but access to 15% of resources. • GDP less than $9075 (World Bank). • Total Health Expenditure (THE) as % GDP often less than 5% as compared to over 10% in the developed world. • Corruption, unstable governments, inconsistent health policies, civil unrest and rapid population growth. • Competing priorities make it impossible for these countries to make resourcesavailable to combat kidney diseases, thus contributing significant challenges to kidney health globally.

32. Global Perspective of CKD in Disadvantaged Populations: Challenges for Third World Countries.Conclusion The governments of Third World Countries are faced with challenges in resource allocation. Therefore, they are unable to provide adequate renal replacement therapy to the patients. Collectively, developed and developing countries must emphasize and implement prevention strategies. The most important emphasis is PREVENTION!!!

33. Muchas Gracias ! !Thank you