Global trends in ESRD epidemiology and impact on Vascular Access

Transcription

1 Global trends in ESRD epidemiology and impact on Vascular Access Wolfgang Meichelboeck, Dipl.-Ing. Pentenried Germany Please respect the copyright when using slides or parts of this presentation 5 th Svenska Accessmötet, Stockholm, Feb 2-3, 2017

2 End Stage Renal Disease (ESRD) and Vascular Access ESRD 3 replacement therapy options: Kidney transplant (Tx) Peritoneal dialysis (PD) Hemodialysis (HD) To perform HD the creation and maintenance of a permanent vascular access (AVF, AVG/shunt or dialysis catheter) is necessary. Picture: courtesy M.K. Widmer, Bern

3 Worldwide ESRD / RRT ~ pat. on RRT All numbers (n) in TX PD HD Moeller S, et al. Nephrol Dial Transplant 2002 Grassmann, NDT 2005, 2014 estimated Fresenius Medical Care, Ann Report 2009, 2010, 2011, 2012, 2013, 2015

4 Worldwide ESRD Treatment Modalities / % Almost no change in RRT treatment modality! 80% 60% 22,9% 23,1% 23,0% 22,8% 22,5% 22,3% 21,7% 21,2% 20,6% 20,1% TX 8,5% 8,4% 8,5% 8,3% 8,3% 8,4% 8,4% 8,5% 8,8% 9,2% PD 58,4% 40% 20% 68,6% 68,5%68,5%68,9%69,2% 69,2% 70,0% 70,3% 70,5% 70,6% HD 8,7% 0% 32,9% Moeller S, et al. NDT 2002, Grassmann, NDT 2005, 2014 estimated Fresenius Medical Care, 2009, 2010, 2011, 2012, 2013, 2015, SVENSKT NJURREGISTER - ÅRSRAPPORT 2016

5 Dialysis population by geographical split (n) in Annual Growth rates % 43% 42% 43% Others China ~ 9% ~ 15% % 12% 13% 8% 9% 34% 3% Japan EU USA ~ 1-2% ~ 2% ~ 3-4% Data Fresenius Medical Care 2014 Others = Asia, Latin America, Middle East, Africa

6 The 15 largest dialysis countries HD vs PD USA China Japan Brazil Mexico Germany India Taiwan Turkey Thailand Korea Italy France Egypt Malaysia HD % PD % 40% 75% 88% 86% 92% 90% 93% 92% 91% 93% 91% 94% 97% 95% 100% 0% 20% 40% 60% 80% 100% 4 European countries Data Fresenius Medical Care 2014 n (%) dialysis population 0% (52%) (23%) 52% 75%

7 SUMMARY EUROPE

8 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.) 100% 80% 36% TX Approx Patients with ESRD on HD in 2013 Approx dialysis centers 60% 4% PD Annual growth rate of Dialysis population approx. 2 % 40% 60% 20% HD Data Fresenius Medical Care 2014, ERCPA providers Info Chart 0% 2013

9 Incidence of RRT in Europe & Incidence (pmp) day 1 - Adjusted for age and gender van de Luijtgarden M. Clin Kidney J (2012)5: , updated with data from ERA-EDTA report 2012, 2013, TR registry data (unadjusted)

10 Prevalence of RRT in Europe & Prevalence (pmp) - Adjusted for age and gender van de Luijtgarden M. Clin Kidney J (2012)5: , updated with data from ERA-EDTA report 2012, 2013, TR registry data (unadjusted)

11 Distribution of the main pathologies contributing to Chronic Kidney Disease (CKD) DM, HT, GN DM DM, HT GN, DM, MS, HT DM, GN, HT, UD DM, GN, HT DM Diabetes Mellitus HT Hypertension GN GN, HT, DM, UD DM, HT GN Glomerulonephritis MS Metabolic Syndrome UD Urological Diseases Nugent RA. Nephron Clin Pract (2011)118:c269-c277

12 The Lancet Global Burden of Disease study - 7 large publications on Global disease trends 1990 vs 2010 Published Dec 15,

13 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 Diabetes 15 9 HT Chronic Kidney Disease Lozano R, Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010 Lancet 2012; 380:

14 Trends for major underlying diseases/factors 14

15 Trends for major underlying diseases 15

16 Trends in Diabetic disease worldwide 2010 to 2030 Adult only years 6,4 % of the adult population 285 Mill. diabetics in Mill. 7,7 % of the adult population 439 Mill. diabetics in 2030 estimated in 2010 Shaw JE, Diab Res Clin Pract (2010) ;87:4-14

17 Diabetes: A global emergency World Diabetes Prev. (Mill.) IDF Diabetes Atlas 2015

18 Diabetes prevalence estimates in European Region Mill 70,0 only in age groups years 66,5 Mill 60,0 50,0 40,0 30,0 55,4 Mill 30,0 Mill 54,3% 40,8 Mill 61,3% years years 20,0 10, years 0,0 Europe 2010 Europe 2030 pop 646,4 Mill. pop 659,3 Mill.

19 Diabetes prevalence Europe / country only in age groups years 16,0% 14,0% National National ,0% 10,0% 8,0% 6,0% 4,0% 2,0% 0,0% Portugal Germany Switzerland Austria Liechtenstein Cyprus Slovenia Latvia Estonia Malta Lithuania Ukraine France Poland Georgia Croatia Belarus Monacoa Bosnia and Herzegovina Russian Federation Bulgaria Andorra Italy Greece Hungary Moldova Spain Czech Republic Serbia Montenegro Romania Finland Macedonia, the Former Belgium San Marino Netherlands Denmark Slovakia Turkey Sweden Israel Azerbaijan Luxembourg Ireland Kazakhstan United Kingdom Albania Norway Kyrgyzstan Turkmenistan Channel Islands Uzbekistan Tajikistan Iceland

20 Trends for major underlying factors 20

21 The global ageing of the population up to 2050 and its impact on ESRD

22 population [billion] The Global ageing and population The elderly population is projected to grow most rapidly! 7% 38% 8% 41% 10% year Source: U.S. Census Bureau, An aging world International population Reports, Nov % 15% 17% 42% 43% 42% 42% 65 y y of age y of age 0-14 y of age

23 Population age structure EU ,1 3,3 4,7 5,8 10,6 12,3 12,7 14,4 7,0 8,9 11,0 12,0 16,6 18,0 17,6 17,5 % ,8 67,2 67,0 64,3 61,7 59,0 57,0 56, ,5 17,2 15,6 15,5 14,7 14,2 14,3 14, years years years 80+ years (1) Excluding French overseas departments in 1990; 2010, provisional; data are projections (EUROPOP2010 convergence scenario). Source: Eurostat (online data codes: demo_pjanind and proj_10c2150p)

24 Incidence of ESRD RRT per million age related population (pmarp) at Day 1 in by age group (pmarp) 75+ y y y y 0 19 y van de Luijtgarden M. Clin Kidney J (2012)5:

25 Median Age incident & prevalent ESRD population Europe Average 62,3 y Average 67,7 y Belgium, Dutch-speaking * Greece 70 67,1 y Italy (12 of 20 regions) # Spain, Castile and Leon * France 65 61,3 y Belgium, French-speaking * Austria Spain, Valencian region Denmark Sweden Croatia The Netherlands Germany - prev.: 1996: 59 years 2006: 66 years 2014: 71 years Prevalent pat. - Median Germany - incid.: 1996: 63 years 2006: 70 years 2014: 72 years Incident pat. - Median Norway Slovakia United Kingdom, All countries * Finland Estonia Bosnia and Herzegovina ERA-EDTA Register Report 2012 selected countries Germany: Quasi-Niere Report 2006/2007

26 Age structure + ESRD Significant increase of the older population over the next 35 years Life longer Increase in age specific diseases (mainly non communicable diseases) many of them also causing ESRD Diabetes Hypertension Cardiovascular Diseases ESRD / HD population is getting older

27 Trends for major underlying diseases 27

28 Trends in hypertensive (HT) disease worldwide to % of the adult population Mill. 29% of the adult population 1,560 Bill. HT adults in Mill. HT adults in Kearney PM Lancet (2005)365:217

29 Prevalence of high Blood pressure by sex (%) Men more likely have high BP Central and Eastern Europe High Income Western Men % Sub-Saharan Africa Women more likely have high BP Others Women % NCD Risk factor Coll. Lancet (2017)365:217

30 Global prevalence of Hypertension (2000 and 2025) Hossain M, American Journal of Kidney Diseases (2009)53: (data from Kearney PM Lancet (2005) 365:217)

31 Prevalence of HT and Overweight/Obesity HYDRA Study n = ; 100% y y y y >75 y 80% 60% 40% 20% 0% Normal BMI Overweight BMI Obesity grade 1 BMI Obesity grade 2 BMI Obesity grade 3 BMI > 40 Bramlage P. Hypertension in Overweight and Obese Primary Care Patients Is Highly Prevalent and Poorly Controlled. Am J Hypertens 2004;17:

32 Trends for major underlying factors

33 Facts on Worldwide Obesity % Obese BMI 30

34 Age-adjusted Prevalence of Obesity and Diagnosed Diabetes Among US Adults Obesity (BMI > 30 kg / m²) Diabetes % 9%

35 WHO facts on Europe Overweight Obese BMI 25 kg/m² BMI 30 kg/m² Several direct and indirect effects on the kidney WHO 07/2013 WHO 03/

36 Europe Obesity Blue more obese Men Purple more obese Women Data from WHO World health statistics 2015

37 Association between obesity and KD based on cohort studies in the general populations (Metaanalysis) Overweight (BMI 25 BMI 30) vs normal weight Obese (BMI 30) vs normal weight Test for heterogeneity: Q=37.11, P=0.003; Pooled RR (95% Cl): 1.40 ( ). Strong correlation with Kidney Diseases Wang Y, Kidney International (2008) 73, Alice RZ, Advances in Chronic Kidney Disease (2013)20: Test for heterogeneity: Q=40.96, P=0.001; Pooled RR (95% Cl): 1.83 ( ).

38 Body Mass Index (BMI) and Risk for End-Stage Renal Disease (ESRD) Adjusted Relative Risk for ESRD 10,0 1,0 0,1 Higher BMI was a risk factor for ESRD in adjusted multivariable models. <18,5 18,5-24,9 25,0-29,9 30,0-34,9 35,0-39,9 >40 BMI in kg/m² adult members of Kaiser Permanente who volunteered for screening health checkups between 1964 and 1985 and who had height and weight measured. Hsu C. Ann Intern Med. 2006;144:21-28.

39 Diabetes CHD Cardiac paod Cerebrovascular Maglignoma Infections COPD Other chronic diseases CO-MORBIDITY

40 HD - Dialysis patients and Comorbidity Dialysis population (HD) prevalent comorbidities 30% diabetes mellitus needing treatment 27% CHD 54% 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 2015 Germany Only 14% of the dialysis patients had no additional diseases Zusammenfassender Jahresbericht QS-Dialyse Germany 2015

41 Comorbidities in Sweden 2014/2015 Komorbidita sjukdomar vid inklusion i CKD-registret SVENSKT NJURREGISTER - ÅRSRAPPORT 2016

42 Co-morbidities / Multimorbidity Elderly nephrologic / ESRD patients Difficult vessel situation Multimorbidity Malnutrition More complications Compliance issues Often no transplant candidates Social and psychological issues Picture: courtesy M.K. Widmer, Bern Vascular access challenges More complex access revisions

43 OUTLOOK

44 The 4 bad guys for the kidney will grow further 44

45 RRT prevalence 25 largest countries in 2014 represent 75% of the world population (= Mill.) Only 11 out of these 25 countries provide RRT above the 2013 world average of 450 pmp countries (China, India, USA, Indonesia, Brazil, Pakistan) 50% of world population population in Mill. ESRD is existing: but often not adequately treated! CHN IND USA IDN BRA PAK NGA BGD RUS JPN MEX PHL VNM ETH EGY DEU IRN TUR COD THA FRA GBR ITA ZAF MMR various sources

46 Dialysis Patients 2013 & 2030 (Millions) In the next 13 years PLUS 4 Million dialysis patients 7 6 Asia-Pacific North America Europe Latin America Middle East Africa Fresenius Medical Care internal estimate (2013)

47 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 ESRD More complex cases / challenges in Vascular Access Interdisciplinary Challenge Adequate training and education IMPORTANT role

48 Future Vascular Access Challenges The access challenge is individual and locally different in the various regions or countries in the world The biggest challenge is however how can we provide adequate and high standard vascular access for all HD patients worldwide!

49 ESRD 2017 ESRD 2020 ESRD 2025 ESRD 2030 ESRD 2040

50 Thank you very much for your attention Acknowledgement: All people around the world who run and contribute to the various ESRD registries