The world-wide epidemiology of CKD

and KDIGO

Norbert LameireEm prof Medicine

University HospitalGent, Belgium

Lysaght, J Am Soc Nephrol, 2002

Number of patients worldwide treated with chronic dialysis from 1990 to 2010

1990 2000 2010

426,000

1,490,000

2,500,000

Incidence of ESRD in EuropeTa

ke-o

n-ra

te p

mp

Jager, van Dijk,NDT (in press-2007).

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

Mild renal dysfunction is (Albuminuria and slight decrease in GFR) is highly prevalent

Stage Description GFR (ml/min/1/73

m2)

Est. Prevalence

USA

Est. Prevalence

GRONINGEN

1 Albuminuria, normal or GFR > 90 3.3% 1.3%

2 Albuminuria, mild GFR 60 - 89 3.0% 3.8%

3 Moderate GFR 30 - 59 4.3% 5.3%4 Severe GFR 15 - 29 0.2% 0.1%

5 Kidney Failure < 15 or RRT 0.2% 0.0%

Total 11.0% 10.5%

Coresh et al; Am J Kidney Dis 2004De Zeeuw et al; Kidney Int; Ali et al Doct Thesis,Aberdeen 2007

K/DOQI Clinical Practical Guidelines Am J Kidney Dis 2003

EstprevScotl

3.1%

> 500,000,000

INDIVIDUALS WITH CHRONIC KIDNEY DISEASE WORLDWIDE

Estrapolated from Coresh et al., Am J Kidney Dis, 2003

End points after 5 years of evolution of 27998 CKD patients (Kaiser-Permanente)

14,910,2

0,010,06

74,8

16,219,5

0,2 0,9

63,3

10,3

24,3

0,2 1,1

64,2

6,6

45,7

2,3

17,6

27,8

01020304050607080

60-89 Stage 2;60-89 Stage 3;30-59 Stage 4;15-29

Disenrolled Died(prior to dial/tx) Received txStart dialysis None of the above

No proteinuria Proteinuria

Keith et al, Arch Int Med 2004,164:659-664.

eGFR

%

Per person cumulative cost by stage of CKD (Kayser Permanente)

16212

38764

18964

33144

19106

41928

05000

1000015000200002500030000350004000045000

Stage 2 Stage 3 Stage 4

age-gender matched controls CKD casesUS $

Smith et al JASN, 15:1300-1306,2004

MDRD estimates

A sm a ll red uc tio n in the g ro w th o f ne w E S R F pa tie n ts m ak es a la rg e im p a c t on th e nu m b ers on d ia lys is

P re va le nce o f A us tra lia n d ia lys is p a tie n ts – ac tu a l d a ta to 20 0 2 w ith p ro je c tio ns to 2 0 2 0

A sm a ll re d u ctio n in the g ro w th o f n e w E S R F pa tien ts m a k es a la rg e im pa c t o n the nu m b ers o n d ia lys is

P re va le nce o f A u s tra lia n d ia lys is p a tie n ts – ac tu a l d a ta to 20 0 2 w ith p ro je c tions to 2 0 2 0

0

5000

10000

15000

20000

25000

1982 86 90 94 98 2 6 10 14 18

# o

f p

ats

6% in cre a se2% in cre a se

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

Where are clinical guidelines coming from?

Where are guidelines coming from?• Sages…, old wise men….,

Prof Medicine,Gent

Em Prof Medicine,Heidelberg

Em Prof Medicine, Gent

May the Force be with you…..

Prof Medicine,Santander

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.

KIDNEY DISEASE IMPROVING GLOBAL OUTCOMES (KDIGO)

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.

KDIGO Board of Directors - 2007Garabed Eknoyan, USA (Co-Chair)Co-Chair)

Norbert Lameire, Belgium (Co-Chair)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

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

KDIGO - Work Groups 2006

Evidence Rating – Alison MacLeod, UK Katrin Uhlig, USA Database Website – Raymond Vanholder, Belgium Nathan Levin, USAImplementation/ 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

KDIGO Initiatives

Clinical Practice Guideline Development Global Guideline Coordination Controversies Conferences Mineral and Bone Initiative International Evidence Review Team

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

Definition and Classification of Chronic Kidney Disease.

A Position Statement from KDIGO

Kidney Int 67:2089-2100, 2005www.kdigo.org

KDIGO modifications from K/DOQI classification

Stage Description GFR (ml/min/1.73 m2)

1 Kidney damage with normal or GFR 90

2 Kidney damage with mild GFR 60-89

3 Moderate GFR 30-59

4 Severe GFR 15-29

5 Kidney failure < 15 (or dialysis)D for dialysis

T for transplant

clinically significant

routine reporting of eGFR based on a standardized serum creatinine

marker of CKD

Iseki K et al. Kidney Int 63:1468-1474, 2003

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17

5

10

15UP ≥3+

UP 2+

UP 1+

UP －0 UP

Yrs after Screening Test

ESRD Incidence and Urinary Protein (UP) in Japan

Cum

ulat

ive

Inci

denc

e (%

)

4th KDIGOControversies Conference

CKD 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

Conceptual model of CKD

Creatinine per method (IDMS 76 µmol/l)

Effect of creatinine calibration on distribution of eGFR

41,8

82,1

45,4

14,5 12,63,2 0,3 0,2

0102030405060708090

> 80 60-79 30-59 < 30

Uncalibrated Calibrated

Per

cent

age

of p

atie

nts

Calibration : - 0.23 mg/dl or 20.3 µmol/LClase et al, JASN 2002,13:2811-2816

Accuracy and precision of the abbreviated MDRD formula in healthy and CKD

populations

Rule et al Ann Intern Med. 2004;141:929-937.

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 womenResults: prevalence of CKD: 5554 pmpMedian 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

Progression of CKD in a large group of unreferred patients in East Kent

0102030405060708090

< 2.O 2.0-2.9 3.0-3.9 4.0-4.9 >5

< 70 70-80 > 80 age

Rate of decline in GFR (ml/min/1.73m²

Percentage

John et al AJKD 43:825-835,2004.

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.

CVDInfections-HIV,-HBV,HCV- malaria,TBMalignancies

Levey et al, KI,2007 (in press).

Public health policy • 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, …”

Thank you