The gap between estimated incidence of end-stage renal disease and use of therapy

Abstract

Background: Relatively few data exist on the burden of end-stage renal disease (ESRD) and use of renal replacement therapy (RRT)-a life-saving therapy-in developing regions. No study has quantified the proportion of patients who develop ESRD but are unable to access RRT.

Methods: We performed a comprehensive literature search to estimate use and annual initiation of RRT worldwide, and present these estimates according to World Bank regions. We also present estimates of survival and of etiology of diseases in patients undergoing RRT. Using data on prevalence of diabetes and hypertension, we modeled the incidence of ESRD related to these risk factors in order to quantify the gap between ESRD and use of RRT in developing regions.

Results: We find that 1.9 million patients are undergoing RRT worldwide, with continued use and annual initiation at 316 and 73 per million population respectively. RRT use correlates directly (Pearson's r = 0.94) with regional income. Hemodialysis remains the dominant form of RRT but there is wide regional variation in its use. With the exception of the Latin American and Caribbean region, it appears that initiation of RRT in developing regions is restricted to fewer than a quarter of patients projected to develop ESRD. This results in at least 1.2 million premature deaths each year due to lack of access to RRT as a result of diabetes and elevated blood pressure and as many as 3.2 million premature deaths due to all causes of ESRD.

Conclusion: Thus, the majority of patients projected to reach ESRD due to diabetes or hypertension in developing regions are unable to access RRT; this gap will increase with rising prevalence of these risk factors worldwide.

Figure 1. World Bank regions.

Six of the seven World Bank regions are organized according to geography. The seventh region, the High Income region (shown here in white) includes North America, Japan, Taiwan, Australia, New Zealand, and European countries–based on a gross national income greater than $12 276 per capita in 2010. Figure adapted from World Bank Regions, Disease Control Priorities Project. www.dcp2.org/page/main/BrowseCountries.html.

Figure 2. Regional income and use of RRT.

Correlation between income and use of RRT in World Bank Regions (Pearson’s r = 0.94). Income is reported as GNP in U.S. dollars per capita PPP from 2005. Abbreviations: RRT-renal replacement therapy, GNP-gross national income, PPP-purchasing power parity, ECA-Eastern Europe and Central Asia, LAC-Latin America and Caribbean, MNA-Middle East and North Africa, EAP-East Asia and Pacific, SA-South Asia and SSA-Sub-Saharan Africa.

Figure 3. Annual initiation of RRT and use of RRT by modality.

Hemodialysis is the most commonly used therapy within developing regions. Transplants are relatively more commonly used and initiated therapies in MNA and SA regions. Peritoneal dialysis is relatively more commonly used and initiated in LAC. Abbreviations: RRT-Renal replacement therapy, HD-Hemodialysis, PD-Peritoneal dialysis, ECA-Eastern Europe and Central Asia, LAC-Latin America and Caribbean, MNA-Middle East and North Africa, EAP-East Asia and Pacific, SA-South Asia and SSA-Sub-saharan Africa.

Figure 4. Proportion of diabetes, hypertension and glomerulonephritis among patients undergoing RRT.

Data for ECA are from registry data representing 60% of its population; for all other developing regions, data are from the most populous country within the region. Abbreviations: HD-Hemodialysis, PD-Peritoneal dialysis, ECA-Eastern Europe and Central Asia, LAC-Latin America and Caribbean, MNA-Middle East and North Africa, EAP-East Asia and Pacific, SA-South Asia and SSA-Sub-Saharan Africa.