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GLOBAL NEPHROLOGY

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

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GLOBAL NEPHROLOGY

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  1. GLOBAL NEPHROLOGY OSMAN LECTURE 2013 John Feehally

  2. 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

  3. 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

  4. RENAL REPLACEMENT THERAPY FOR END-STAGE RENAL DISEASE Dialysis and kidney transplant …are a fantastic success story

  5. Government Attitudes to Kidney Disease Until ~ 10 years ago …… They were driven by concern about the cost of renal replacement therapy and were pleased that kidney disease was uncommon

  6. ESRD is increasingly common worldwide 2,500,000 1,490,000 426,000 1990 2010 2000 6 Lysaght, MJ. JASN 2002; 13: S37

  7. GLOBAL TREATMENT FOR ESRD 60% treated in 5 countries (Brazil, Germany, Italy, Japan, US) Representing <12 % world population Moeller S et al. NDT 2002;17:2071

  8. GLOBAL TREATMENT FOR ESRD 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 Moeller S et al. NDT 2002;17:2071

  9. GLOBAL TREATMENT FOR ESRD 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 Remaining 20% in over 100 countries Representing > 50% world population Moeller S et al. NDT 2002;17:2071

  10. 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.

  11. ‘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

  12. WORLD BANK CLASSIFICATION OF ECONOMIES

  13. Prevalent patients on RRT and GDP per capita2002 White et al, Bulletin WHO, March 2008

  14. Outcome of chronic HD in NigeriaMortality Percent mortality < 1 mth 1-3 mths 3-6 mths 6-9 mths 9-12 mths

  15. Reasons for stopping dialysis in Nigeria Ulasi, Ijoma J Trop Med, 2010, 50:1957

  16. ‘BRIC’ COUNTRIES Brazil Russia India China

  17. RRT in Mainland China 20-30% HD PD TRANSPLANTATION 5,500 162,090 10% 22,000 5,500 127,451 134,591 17,280 104,671

  18. Prevalence of RRT in some Asian countries HK Japan Taiwan 18

  19. Prevalence of RRT in some Asian countries 33 37 40 45 53 66 83 116 03 04 05 06 07 08 09 10 中国大陆 Mainland China HK Japan Taiwan 19

  20. DEVELOPING ECONOMIES BRICCOUNTRIES Brazil - Russia - India - China What drives increases in RRT ? Economic growth Healthcare systems Commercial influence Population expectation Physician reimbursement

  21. ETHICAL DIALYSIS Diligence is needed if the rapid growth of dialysis in some developing countries is to proceed to the highest ethical standards It is the responsibility of the global nephrology community to set the standards

  22. ETHICAL DIALYSIS Diligence is needed if the rapid growth of dialysis in some developing countries is to proceed to the highest ethical standards Task Force on Ethical Standards in Dialysis 2013

  23. Comparison of unadjusted ESRD prevalence worldwide All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.

  24. Comparison of unadjusted ESRD prevalence worldwide How do we interpret such growth yet variablity ? Success? Failure? Good care? ‘Rationing’ ? All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.

  25. 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.

  26. 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

  27. RACIAL SUSCEPTIBILITY TO TYPE 2 DIABETIC KIDNEY DISEASE South Asians Pacific Islanders Australian Aborigines African Caribbeans Hispanics Native Americans

  28. 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 ?

  29. ABORIGINAL AUSTRALIANSSOCIO-ECONOMIC DISADVANTAGE AND ESRD Cass A et al Ethnicity & Disease 2002; 12: 373

  30. However “successful” a dialysis programme may be…. ….. dialysis patients are uniquely vulnerable to ‘events beyond our control’

  31. RENAL DISASTER RELIEF • TASK FORCE The Fellowship Program

  32. Comparison of unadjusted ESRD prevalence worldwide All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.

  33. Comparison of unadjusted ESRD incidence worldwide UK All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.

  34. Comparison of unadjusted ESRD incidence worldwide The tide can be turned UK All rates are unadjusted. Data from Argentina (2005–2007), Japan, & Taiwan are dialysis only.

  35. KIDNEY TRANSPLANTATION The underused option Deceased and living donor Cost effective Affordable in some countries where dialysis is not

  36. KIDNEY TRANSPLANTATION The underused option Deceased and living donor Cost effective Affordable in some countries where dialysis is not BUT Cultural influences Commercial pressures Exploitation Transplant tourism

  37. Chronic Kidney Disease Only 10 years since the K/DOQI Classification of Chronic Kidney Disease was first published

  38. 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 ?

  39. PREVALENCE OF CKD High income countries USA - UK

  40. PREVALENCE OF CKD High income countries USA - UK Upper middle income countries Belarus - China - Mexico Lower middle income countries Bolivia - Moldova Low income countries Nepal

  41. 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

  42. CKD often coexists with other NCDs Hypertension Diabetes CKD Cardiovascular disease

  43. Chronic Kidney Disease – A VASCULAR DISEASE ?

  44. Chronic Kidney Disease – A VASCULAR DISEASE ? GAIN Entry to ‘mainstream’ NCD policy A ‘seat at the table’ We can discuss large populations at risk

  45. Chronic Kidney Disease – A VASCULAR DISEASE ? GAIN Entry to ‘mainstream’ NCD policy A ‘seat at the table’ We can discuss large populations at risk RISKS A change of message

  46. Chronic Kidney Disease – A VASCULAR DISEASE ? GAIN Entry to ‘mainstream’ NCD policy A ‘seat at the table’ We can discuss large populations at risk RISKS 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”

  47. ‘Chronic Kidney Disease’ CKD as a vascular disease But NOT ONLY a vascular disease

  48. ‘Chronic Kidney Disease’ CKD as a vascular disease ….. but NOT ONLY a vascular disease United States 28% of those with CKD do not have hypertension, or diabetes USRDS

  49. ‘Chronic Kidney Disease’ CKD as a vascular disease ….. but NOT ONLY a vascular disease United States 28% of those with CKD do not have hypertension, or diabetes USRDS China – Mongolia - Nepal 43% of those with CKD do not have cardiovascular disease, hypertension, or diabetes Sharma SK et al. AJKD 2010; 56: 915

  50. ‘Chronic Kidney Disease’ Up to ~40% of those with CKD do not have cardiovascular disease, hypertension, or diabetes Communicable disease Glomerulonephritis Hereditary/congenital diseases Stones Environmental factors

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