The world-wide epidemiology of CKD and KDIGO Norbert Lameire Em prof Medicine University Hospital

1. The world-wide epidemiology of CKD and KDIGO Norbert Lameire Em prof Medicine University Hospital Gent, Belgium

2. 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

3. Incidence of ESRD in Europe Take-on-rate pmp Jager, van Dijk,NDT (in press-2007).

4. Incidence of ESRD in EDTA/ERA Registry from 1991-2001

5. Mild renal dysfunction is (Albuminuria and slight decrease in GFR) is highly prevalent Est prev Scotl 3.1% Coresh et al; Am J Kidney Dis 2004 De Zeeuw et al; Kidney Int; Ali et al Doct Thesis,Aberdeen 2007 K/DOQI Clinical Practical Guidelines Am J Kidney Dis 2003

6. INDIVIDUALS WITH CHRONIC KIDNEY DISEASE WORLDWIDE > 500,000,000 Estrapolated from Coresh et al., Am J Kidney Dis, 2003

7. End points after 5 years of evolution of 27998 CKD patients (Kaiser-Permanente) % No proteinuria eGFR Proteinuria Keith et al, Arch Int Med 2004,164:659-664.

8. Per person cumulative cost by stage of CKD (Kayser Permanente) US $ MDRD estimates Smith et al JASN, 15:1300-1306,2004

10. Why do we need Guidelines? • Information overload • Many effective treatments • Increased outcomes research • Identify gaps in clinical knowledge • Need to quantify outcome related performance • Increasing costs of medical care • Realization of limited resources • Improve accountability • Changing patient-physician relationships • Higher expectations of an increasingly educated public

12. Where are clinical guidelines coming from?

14. Where are guidelines coming from? • Sages…, old wise men…., Em Prof Medicine, Heidelberg Prof Medicine,Gent Em Prof Medicine, Gent May the Force be with you….. Prof Medicine, Santander

15. Rationale for a Global Initiative There is an increasing prevalence of kidney disease worldwide. The complications and problems of patients with kidney disease are universal. Resources may vary, but the science and evidence-based care of patients with kidney disease are independent of geographical location or national borders. There is room for improving international cooperation in the development, dissemination and implementation of clinical practice guidelines.

17. Independently incorporated, non-profit foundation governed by an international board with the stated mission to: Improve the care and outcomes of kidney disease patients worldwide by promoting coordination, collaboration, and integration of initiatives to develop and implement clinical practices guidelines. KIDNEY DISEASE IMPROVING GLOBAL OUTCOMES (KDIGO)

18. Garabed Eknoyan, USA (Co-Chair) Norbert Lameire, Belgium (Co-Chair) Mona Al-Rukhaimi, UAE Sharon Andreoli, USA Mustafa Arici, Turkey Kamal Badr, Lebanon Rashad Barsoum,Egypt Gavin J. Becker,Australia Ezequiel Bellorin,Venezuela Fred Brown, USA Emmanuel Burdman,Brazil Evelyn Butera, USA Jorge Cannata, Spain Jeremy Chapman, Australia Ricardo Correa-Rotter, Mexico Olivier Coustere, France Jonathon Craig, Australia Bruce Culleton, Canada Angel de Francisco, Spain Paul de Jong, Netherlands Jean-Yves DeVos, Belgium Kai-Uwe Eckardt,Germany Knut Erben, Germany Dennis Fouque,France Gordon Guyatt, Canada Vivekanand Jha,India Michelle Josephson, USA Bertram Kasiske,USA Adeera Levin,Canada Nathan Levin,USA Phillip Li, Hong Kong Francesco Locatelli,Italy Alison MacLeod,UK Linda McCann, USA KDIGO Board of Directors - 2007 Peter McCullough, USA Sarala Naicker,South Africa Brian Pereira, USA Miguel Riella, Brazil Jerome Rossert,France Yusuke Tsukamoto, Japan Raymond Vanholder,Belgium Yves Vanrenterghem, Belgium Giancarlo Viberti, UK Rowan Walker,Australia Hyan Wang,China Jan Weening, Netherlands David Wheeler, UK Carmine Zoccali,Italy

19. KDIGO -Work Groups 2006 Evidence Rating – Alison MacLeod, UK Katrin Uhlig, USA Database Website – Raymond Vanholder, Belgium Nathan Levin, USA Implementation/ Regions with CPGs – Norbert Lameire, Belgium Francesco Locatelli, Italy Implementation/ Regions without CPGs- Vivek Jha, Egypt E. Burdmann, Brazil Mineral and Bone Disorder – Sharon Moe, USA Tilman Drüeke, France Liaison Task Force –Raymond Vanholder, Belgium

20. KDIGO Initiatives • Clinical Practice Guideline Development • Global Guideline Coordination • Controversies Conferences • Mineral and Bone Initiative • International Evidence Review Team

21. KDIGO Activities in 2006 • Controversies Conferences: Transplant Recipient; CKD a Global Public Health Problem • Position Statements:Definition, Evaluation and Classification of ROD, Grading of Evidence and Recommendations of CPGs • Guideline Coordination:Liaison Task Force, Annual Organizational Meeting with 5 guideline organizations and ISN • Coordination with WHO: Liaison member on Guideline Development Groups, Incorporate CKD Staging in ICD 10-11, WHO Guidelines on Guidelines methodology • Clinical Practice Guidelines: Hepatitis C; CKD-MBD; Care of the Kidney Transplant Recipient

22. Definition and Classification of Chronic Kidney Disease.A Position Statement from KDIGO Kidney Int 67:2089-2100, 2005 www.kdigo.org

23. KDIGO modifications from K/DOQI classification

24. routine reporting of eGFR based on a standardized serum creatinine clinically significant Tfor transplant Dfor dialysis

26. marker of CKD

27. ESRD Incidence and Urinary Protein (UP) in Japan UP ≥3+ Cumulative Incidence (%) 15 10 UP 2+ 5 UP 1+ UP  0 UP－ 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Yrs after Screening Test Iseki K et al. Kidney Int 63:1468-1474, 2003

28. 4th KDIGOControversies ConferenceCKD as a Global Health Problem: Approaches and InitiativesCo-Chairs: Andrew Levy, Kai-Uwe Eckardt, Adeera Levin, Allan Collins, Meguid El-Nahas October 12-14, 2006

29. Conceptual model of CKD

30. Creatinine per method (IDMS 76 µmol/l)

31. Effect of creatinine calibration on distribution of eGFR Percentage of patients Calibration : - 0.23 mg/dl or 20.3 µmol/L Clase et al, JASN 2002,13:2811-2816

32. Accuracy and precision of the abbreviated MDRD formula in healthy and CKD populations Rule et al Ann Intern Med. 2004;141:929-937.

33. Prevalence of CKD in East Kent • Population of East Kent: 688.193 • Stable renal function at follow up determination • Laboratory results in 2 labs: • Screat ≥ 2.03 mg/dl in men; ≥ 1.53 mg/dl in women Results: prevalence of CKD: 5554 pmp Median GFR: 28,5 ml/min; median age: 83 yrs (18-103yrs) Unknown to renal services: 84,8% Outcomes of referred group: mean survival 29.1 months of unreferred group: mean survival 27.4 months (p< 0.001) John et al AJKD 43:825-835,2004

34. Progression of CKD in a large group of unreferred patients in East Kent age Percentage Rate of decline in GFR (ml/min/1.73m² John et al AJKD 43:825-835,2004.

35. Who to screen? Target groups should include patients with hypertension, diabetes and cardiovascular disease. Other groups might include families of patients with CKD, individuals with hyperlipidemia, obesity, metabolic syndrome, smokers, patients treated with medications with potential toxicity to the kidneys, some infectious diseases (HIV, HBV, HCV), cancer patients, and age > 60 years.

36. CVD • Infections • HIV, • HBV,HCV • malaria,TB • Malignancies Levey et al, KI,2007 (in press).

37. Governments should adopt a public health policy for CKD. CKD is an integral part of a cluster of chronic diseases, including hypertension, diabetes, and cardiovascular disease. Within each of these groups, the CKD population is the group at highest risk and highest priority for intensivecare and close monitoring. Governments should partner with non-governmental organizations and industry (at the regional, national, and international level) to support the incorporation of CKD into public health agendas. Governments should support programs for detection, surveillance, evaluation and management of CKD. The program would document the prevalence, incidence, outcomes, care and education of the public and health care providers. Specific recommendations for screening and surveillance will be included in the published position statement. Governments should support a public awareness program for CKD. The public awareness program should present a simple message: CKD is common, harmful and treatable, and individuals should “Know Their A, B, C’s:” Albuminuria, Blood Pressure, Cholesterol, Diabetes, Estimated GFR, …” Public health policy

38. Thank you