global trends in esrd epidemiology and impact on...

Global trends in ESRD epidemiology and impact on Vascular Access

Wolfgang Meichelboeck, Dipl.-Ing.Pentenried – Germany

5th Svenska Accessmötet, Stockholm, Feb 2-3, 2017

[email protected] respect the copyright when using slides or parts of this presentation

© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017

End Stage Renal Disease (ESRD) and Vascular Access

ESRD – 3 replacement therapy options:Kidney transplant (Tx)Peritoneal dialysis (PD)Hemodialysis (HD)

To perform HD thecreation and maintenanceof a permanent vascular access(AVF, AVG/shunt or dialysis catheter)is necessary.

Picture: courtesy M.K. Widmer, Bern


0

500

1.000

1.500

2.000

2.500

3.000

3.500

4.000

2001 2004 2008 2009 2010 2011 2012 2013 2014 2015

TX

PD

HD

Worldwide ESRD / RRT – 2001 - 2015

Moeller S, et al. Nephrol Dial Transplant 2002Grassmann, NDT 2005, 2014 estimatedFresenius Medical Care, Ann Report 2009, 2010, 2011, 2012, 2013, 2015

2015 ~ 3.572 pat. on RRT

1.479

1.783

All numbers (n) in .000

2.3052.455

2.6322.786

3.0103.200

3.360


0%

20%

40%

60%

80%

100%

2001 2004 2008 2009 2010 2011 2012 2013 2014 2015

68,6%68,5%68,5%68,9%69,2%69,2% 70,0% 70,3% 70,5% 70,6%

8,5% 8,4% 8,5% 8,3% 8,3% 8,4% 8,4% 8,5% 8,8% 9,2%

22,9% 23,1% 23,0% 22,8% 22,5% 22,3% 21,7% 21,2% 20,6% 20,1% TX

PD

HD

Worldwide ESRD Treatment Modalities / 2001 – 2015

Moeller S, et al. NDT 2002, Grassmann, NDT 2005, 2014 estimatedFresenius Medical Care, 2009, 2010, 2011, 2012, 2013, 2015, SVENSKT NJURREGISTER - ÅRSRAPPORT 2016

Almost no change in RRT treatment modality !

2015

32,9%

8,7%

58,4%


Dialysis population by geographical split

0

500

1.000

1.500

2.000

2.500

3.000

2000 2005 2010 2011 2012 2013

Others

China

Japan

EU

USA

43%

34%

38%

42%

42%43%

13%12%9%8%3%

Data Fresenius Medical Care 2014

Annual Growth rates

~ 9%

~ 15%

~ 1-2%

~ 2%

~ 3-4%

(n) in .000

Others = Asia, Latin America, Middle East, Africa


The 15 largest dialysis countries 2013 - HD vs PD

91%

100%

93%

91%

86%

75%

92%

90%

93%

95%

40%

94%

97%

88%

92%

0% 20% 40% 60% 80% 100%

MalaysiaEgypt

FranceItaly

KoreaThailand

TurkeyTaiwan

IndiaGermany

MexicoBrazilJapanChina

USA

HD % PD %

4 European countries Data Fresenius Medical Care 2014

1.309.000(52%)

576.000(23%)

0%

52%

75%

n (%) dialysispopulation


SUMMARYEUROPE


ESRD and RRT in Europe Approx. 50 Mill. Patients with chronic kidney disease

(10% of the population) CKD stages 3–5 prevalence varied from 1.0% to 5.9%

(approx. 36 Mill.)

Approx. 350.000 Patients with ESRD on HD in 2013 Approx. 5.400 dialysis centers

Annual growth rate of Dialysis population approx. 2 %

Data Fresenius Medical Care 2014, ERCPA providers Info Chart

60%

4%

36%

0%

20%

40%

60%

80%

100%

2013

TX

PD

HD


Incidence of RRT in Europe2005 - 2009 & 2012 - 2013 - 2014

0

50

100

150

200

250

3002005 2006 2007 2008 2009 2012 2013 2014

van de Luijtgarden M. Clin Kidney J (2012)5: 109-119, updated with data from ERA-EDTA report 2012, 2013, 2014+ TR registry data (unadjusted)

Incidence (pmp) day 1 - Adjusted for age and gender


Prevalence of RRT in Europe2005 - 2009 & 2012 - 2013 - 2014

0

200

400

600

800

1000

1200

1400

16002005 2006 2007 2008 2009 2012 2013 2014

Prevalence (pmp) - Adjusted for age and gendervan de Luijtgarden M. Clin Kidney J (2012)5: 109-119, updated with data from ERA-EDTA report 2012, 2013, 2014 + TR registry data (unadjusted)


Distribution of the main pathologies contributing toChronic Kidney Disease (CKD)

GN, DM, MS, HT

DM, HT

DM, GN, HT

DM, HT

GN, HT, DM, UD

DM, HT, GN

DM

GN

DM, GN, HT, UD

DM – Diabetes Mellitus

HT – Hypertension

GN – Glomerulonephritis

MS – Metabolic Syndrome

UD – Urological Diseases

Nugent RA. Nephron Clin Pract (2011)118:c269-c277


The Lancet 2012- Global Burden of Disease study -

7 large publications onGlobal disease trends

1990 vs 2010

Published Dec 15, 2012

12http://www.thelancet.com/themed/global-burden-of-disease


Lozano R, Global and regional mortality from 235 causes of death for20 age groups in 1990 and 2010: a systematic analysis forthe Global Burden of Disease Study 2010 Lancet 2012; 380: 2095–128

Global death ranks with 95% UIs for the top 25 causes in 1990 and 2010, and the percentage change with 95% CIs between 1990 and 2010

Diabetes15 9

ChronicKidneyDisease27 18

HT18 14

1990 2010


Trends for major underlying diseases/factors

14


Trends for major underlying diseases

15


Trends in Diabetic disease worldwide2010 to 2030

Shaw JE, Diab Res Clin Pract (2010) ;87:4-14

+ 154 Mill.

439 Mill. diabeticsin 2030

285 Mill.diabeticsin 2010

Adult only20-79 years

6,4 % of theadult

population

7,7 % of theadult

population

estimated in 2010


Diabetes: A global emergency

IDF – Diabetes Atlas 2015

415

642

0

100

200

300

400

500

600

700

2015 2040

World Diabetes Prev. (Mill.)


Diabetes prevalence estimates in European Region 2010 – 2030

0,0

10,0

20,0

30,0

40,0

50,0

60,0

70,0

Europe 2010 Europe 2030

60-79 years

40-59 years

20-39 years

http://www.idf.org/diabetesatlas/

55,4 Mill

66,5 Mill

30,0 Mill54,3%

40,8 Mill61,3%

Mill only in age groups 20-79 years

pop 646,4 Mill. pop 659,3 Mill.


Diabetes prevalence Europe / country - 2010 - 2030

0,0%

2,0%

4,0%

6,0%

8,0%

10,0%

12,0%

14,0%

16,0%

Por

tuga

lG

erm

any

Sw

itzer

land

Aus

tria

Liec

hten

stei

nC

ypru

sS

love

nia

Latv

iaE

ston

iaM

alta

Lith

uani

aU

krai

neFr

ance

Pol

and

Geo

rgia

Cro

atia

Bel

arus

Mon

acoa

Bos

nia

and

Her

zego

vina

Rus

sian

Fed

erat

ion

Bul

garia

And

orra

Italy

Gre

ece

Hun

gary

Mol

dova

Spa

inC

zech

Rep

ublic

Ser

bia

Mon

tene

gro

Rom

ania

Finl

and

Mac

edon

ia, t

he F

orm

er…

Bel

gium

San

Mar

ino

Net

herla

nds

Den

mar

kS

lova

kia

Turk

eyS

wed

enIs

rael

Aze

rbai

jan

Luxe

mbo

urg

Irela

ndK

azak

hsta

nU

nite

d K

ingd

omA

lban

iaN

orw

ayK

yrgy

zsta

nTu

rkm

enis

tan

Cha

nnel

Isla

nds

Uzb

ekis

tan

Tajik

ista

nIc

elan

d

National - 2010 National - 2030

only in age groups 20-79 years

http://www.idf.org/diabetesatlas/


Trends for major underlying factors

20


The global ageing of the populationup to 2050 and its impact on ESRD

2002

20502030


The Global ageing and population 2002 - 2050

The elderly population is projected to grow most rapidly !

Source: U.S. Census Bureau, An aging world –International population Reports, Nov 2001

0123456789

10

2002 2010 2020 2030 2040 2050 year

popu

latio

n [b

illio

n]

65 y +

30-64 yof age

15-29 yof age

0-14 yof age

7%8%

10%12%

15% 17%

38% 41%42% 43% 42% 42%


Population age structureEU-27 1990 - 2060

19,5 17,2 15,6 15,5 14,7 14,2 14,3 14,2

66,867,2 67,0 64,3

61,7 59,0 57,0 56,2

10,6 12,3 12,7 14,4 16,6 18,0 17,6 17,5

3,1 3,3 4,7 5,8

7,0 8,9 11,0 12,0

0

10

20

30

40

50

60

70

80

90

100

1990 2000 2010 2020 2030 2040 2050 2060

%

0-14 years 15-64 years 65-79 years 80+ years(1) Excluding French overseas departments in 1990; 2010, provisional; 2020-2060 data are projections (EUROPOP2010 convergence scenario).

Source: Eurostat (online data codes: demo_pjanind and proj_10c2150p)

2017


Incidence of ESRD RRT per million age related population (pmarp) at Day 1 in 2009

0200400600800

1.0001.2001.4001.6001.8002.000

by age group (pmarp)

75+ y

65–74 y

45–64 y

20–44 y

0–19 y

van de Luijtgarden M. Clin Kidney J (2012)5: 109-119


Median Age incident & prevalentESRD population Europe - 2012

55

60

65

70

75

Prevalent pat. - Median Incident pat. - Median

Belgium, Dutch-speaking *

Greece

Italy (12 of 20 regions) † #

Spain, Castile and Leon *

France

Belgium, French-speaking *

Austria

Spain, Valencian region

Denmark

Sweden

Croatia

The Netherlands

Norway

Slovakia †

United Kingdom, All countries *

Finland

Estonia

Bosnia and Herzegovina

ERA-EDTA Register Report 2012 – selected countriesGermany: Quasi-Niere Report 2006/2007

Germany - prev.:1996: 59 years2006: 66 years2014: 71 years

Germany - incid.:1996: 63 years2006: 70 years2014: 72 years

Average 62,3 y Average 67,7 y

61,3 y

67,1 y


Age structure + ESRD

Significant increase of the older populationover the next 35 years – Life longer

Increase in age specific diseases(mainly non communicable diseases)many of them also causing ESRD

DiabetesHypertensionCardiovascular Diseases

ESRD / HD population is getting older


Trends for major underlying diseases

27


Trends in hypertensive (HT) disease worldwide - 2000 to 2025

Kearney PM Lancet (2005)365:217

+ 588 Mill.

1,560 Bill.HT adultsin 2025

972 Mill.HT adultsin 2000

26% of theadult

population

29% of theadult

population

2017


Prevalence of high Blood pressure by sex (%) - 2015

Central and Eastern Europe

High Income Western

Sub-Saharan Africa

Others

Women %

NCD Risk factor Coll. Lancet (2017)365:217

Men

%

Men more likelyhave high BP

Women more likelyhave high BP


Global prevalence of Hypertension (2000 and 2025)

Hossain M, American Journal of Kidney Diseases (2009)53: 166-174(data from Kearney PM Lancet (2005) 365:217)


Prevalence of HT and Overweight/Obesity

0%

20%

40%

60%

80%

100%

Normal BMI 18.5–24.9 Overweight BMI 25–29.9

Obesity grade 1 BMI 30–34.9

Obesity grade 2 BMI 35–39.9

Obesity grade 3 BMI >40

16-29 y 30-44 y 45-59 y 60-74 y >75 y

Bramlage P. Hypertension in Overweight and Obese Primary Care PatientsIs Highly Prevalent and Poorly Controlled. Am J Hypertens 2004;17:904–910

HYDRA Study – n = 38.873; http://www.hydra-studie.de


Trends for major underlying factors


Facts on Worldwide Obesity - 2014

www.metrocosm.com

% Obese BMI ≥ 30


Age-adjusted Prevalence of Obesity and Diagnosed DiabetesAmong US Adults

Obesity (BMI > 30 kg / m²)

Diabetes

1994 2000 2014

1994 2000 2014

≥ 26%

≥ 9%


WHO facts on Europe

.http://www.euro.who.int/en/health-topics/noncommunicable-diseases/obesity

Overweight BMI ≥ 25 kg/m²Obese BMI ≥ 30 kg/m²Several direct and indirect

effects on the kidney

© WHO 07/2013

© WHO 03/2014

www.euro.who.int/obesity


Europe Obesity - 2014

Data from WHO „World health statistics 2015“

Blue moreobese Men

Purple moreobese Women


Association between obesity and KD based on cohort studies in the general populations (Metaanalysis)

.Wang Y, Kidney International (2008) 73, 19–33Alice RZ, Advances in Chronic Kidney Disease (2013)20:121-127

Overweight (BMI 25 ≥–BMI ≤ 30) vs normal weight

Obese (BMI ≥ 30) vs normal weight

Strong correlation with Kidney Diseases

Test for heterogeneity: Q=37.11, P=0.003; Pooled RR (95% Cl): 1.40 (1.30 –1.50).

Test for heterogeneity: Q=40.96, P=0.001;Pooled RR (95% Cl): 1.83 (1.57–2.13).


Body Mass Index (BMI) and Risk for End-Stage Renal Disease (ESRD)

.Hsu C. Ann Intern Med. 2006;144:21-28

<18,5 18,5-24,9 25,0-29,9 30,0-34,9 35,0-39,9 >40

BMI in kg/m²320.252 adult members of Kaiser Permanente who volunteered for screening health checkups

between 1964 and 1985 and who had height and weight measured.

Higher BMI was a risk factor for ESRD in adjusted multivariable models.

Adj

uste

dR

elat

ive

Ris

kfo

rES

RD

1,0

10,0

0,1


CO-MORBIDITY

DiabetesCHDCardiacpAODCerebrovascularMaglignomaInfectionsCOPDOther chronic diseases


Only 14% of the dialysis patients had no additional diseases

HD - Dialysis patients and Comorbidity

Dialysis population (HD) prevalent comorbidities30% diabetes mellitus needing treatment27% CHD54% other cardiac diseases,13% peripheral arterial occl. disease (pAOD),11% cerebrovascular diseases,9% malignoma,4% chronic infections,2% demecia, 3% Polyneuropthia, 3% depression

46% had other chronic diseases

Zusammenfassender Jahresbericht QS-Dialyse Germany – 2015

2015 Germany


Comorbidities in Sweden – 2014/2015

SVENSKT NJURREGISTER - ÅRSRAPPORT 2016

Komorbidita sjukdomar vid inklusion i CKD-registret 2014-2015


Co-morbidities / Multimorbidity

Elderly nephrologic / ESRD patientsDifficult vessel situationMultimorbidityMalnutritionMore complicationsCompliance issuesOften no transplant candidatesSocial and psychological issues

Vascular access challengesMore complex access revisions

Picture: courtesy M.K. Widmer, Bern


OUTLOOK


The 4 bad guys for the kidneywill grow further

44


RRT prevalence 25 largest countries in 2014

represent 75% of the world population (= 7.200 Mill.)

1.36

7

1.26

5

320

255

204

187

185

158

146

127

121

101

93 91 88 81 81 81 71 68 66 64 62 54 56

0

200

400

600

800

1.000

1.200

1.400

1.600C

HN

IND

USA ID

N

BR

A

PAK

NG

A

BG

D

RU

S

JPN

MEX PH

L

VNM

ETH

EGY

DEU IR

N

TUR

CO

D

THA

FRA

GB

R

ITA

ZAF

MM

R

population in Mill.6 countries(China, India,

USA, Indonesia,Brazil, Pakistan)

50% of world population

various sources

Only 11 out of these 25 countries provide RRT above the 2013 world average of 450 pmp

ESRD is existing:but often not adequately treated !


Dialysis Patients 2013 & 2030 (Millions)

In the next 13 years PLUS 4 Million dialysis patients

Fresenius Medical Care internal estimate (2013)

0

1

2

3

4

5

6

7

2013 2030

Asia-Pacific

North America

Europe

Latin America

Middle East

Africa

+2.300.000

+632.000

+319.000

+308.000

+210.000

+156.000


Conclusion – Epidemiologics Aspects

Further increase prevalent HD population

High prevalence of Diabetes, HT and Obesity

Increasing Age of the incident and prevalent patients

Elderly multimorbid nephrologic patient with ESRDMore complex cases / challenges in Vascular Access

Interdisciplinary Challenge

Adequate training and education – IMPORTANT role


Future Vascular Access Challenges

The access challenge isindividual and locally different in the various regions or countries in the world

The biggest challenge is howeverhow can we provideadequate and high standard vascular access for all HD patients worldwide !


ESRD 2017

ESRD 2020

ESRD 2025

ESRD 2030

ESRD 2040


Thank you very much for your attention

Acknowledgement:

All people around the worldwho run and contribute to

the various ESRD registries

global trends in esrd epidemiology and impact on...

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