Upload
others
View
10
Download
0
Embed Size (px)
Citation preview
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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%
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
SUMMARYEUROPE
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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)
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Trends for major underlying diseases/factors
14
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Trends for major underlying diseases
15
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Diabetes: A global emergency
IDF – Diabetes Atlas 2015
415
642
0
100
200
300
400
500
600
700
2015 2040
World Diabetes Prev. (Mill.)
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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.
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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/
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Trends for major underlying factors
20
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
The global ageing of the populationup to 2050 and its impact on ESRD
2002
20502030
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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%
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Trends for major underlying diseases
27
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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)
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Trends for major underlying factors
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Facts on Worldwide Obesity - 2014
www.metrocosm.com
% Obese BMI ≥ 30
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Age-adjusted Prevalence of Obesity and Diagnosed DiabetesAmong US Adults
Obesity (BMI > 30 kg / m²)
Diabetes
1994 2000 2014
1994 2000 2014
≥ 26%
≥ 9%
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Europe Obesity - 2014
Data from WHO „World health statistics 2015“
Blue moreobese Men
Purple moreobese Women
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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).
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
CO-MORBIDITY
DiabetesCHDCardiacpAODCerebrovascularMaglignomaInfectionsCOPDOther chronic diseases
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Comorbidities in Sweden – 2014/2015
SVENSKT NJURREGISTER - ÅRSRAPPORT 2016
Komorbidita sjukdomar vid inklusion i CKD-registret 2014-2015
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
OUTLOOK
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
The 4 bad guys for the kidneywill grow further
44
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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 !
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
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 !
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
ESRD 2017
ESRD 2020
ESRD 2025
ESRD 2030
ESRD 2040
© wm @ Svenska Accessmötet(Stockholm, Sweden), Feb 2017
Thank you very much for your attention
Acknowledgement:
All people around the worldwho run and contribute to
the various ESRD registries