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This international chapter has expanded each year as more countries participate in the collaborative effort to collate data for the public health surveillance of end-stage renal disease. This year, 46 countries have graciously sent data to the USRDS. Not only does such information allow for international comparisons; it also provides a context for data on the multiple ethnic and racial groups which constitute the diverse population of the U.S.. The USRDS is well aware of the considerable challenges each country faces in gathering its data, and sincerely thanks the registries and providers for their efforts.
Reported rates of incident ESRD across the globe show important trends; rates have slowed in some countries, while rising or remaining stable in others. Taiwan, the U.S., and Japan continue to have some of the highest rates, at 384, 362, and 288 per million population. And in Mexico, rates in Morelos and Jalisco reached 557 and 400, respectively.
The high and rising rates noted in Taiwan have been of great interest, as they eclipse rates reported in the rest of the world. It had appeared that such growth would continue, but rates now seem to have peaked, with a recent decline paralleling that seen in the U.S. Recent changes to payment policies for treated ESRD populations in Taiwan may impact these lower rates. More importantly, there have been a number of initiatives to address the care of patients with CKD and diabetes. More time is need to determine if this improvement can be sustained, given the aging of the Taiwanese population and its high burden of diabetes.
This year we introduce comparisons of ESRD incidence among Asian populations in Japan, Taiwan, and the U.S., and among native populations in Australia, New Zealand, the U.S., and Canada. These comparisons are the direct result of a significant collaboration between the Australian and New Zealand Dialysis and Transplant Registry (ANZDATA), the Japanese Society of Dialysis Therapy (JSDT), the Taiwan Society of Nephrology (TSN), and the Canadian Organ Replacement Registry (CORR). The almost universal voluntary reporting by these systems make them distinct in the way they capture information on treated ESRD. We have selected similar populations within the U.S. to highlight trends in ESRD and changes in the burden of kidney failure. Each of these countries has a unique health care delivery system, and unique issues in access to care. They also have high relative incomes per capita and advanced systems both of general health care and of public healthcare to address major chronic diseases. In Taiwan and Japan, for example, all populations receive universal health care coverage, and dialysis therapy has been available for many years. In the U.S., universal coverage applies only to ESRD, but has recently expanded under new legislation.
This is the first in a series of collaborations between the USRDS and ESRD surveillance systems around the world, as we work to provide new perspectives on treated ESRD in unique populations with different healthcare systems. We wish once again to thank JSDT, TSN, CORR, and ANZDATA for their collaboration. Data will be sent to each of the participating countries for further analysis and for presentation within their own registries, and the USRDS will provide web links to these data as well.
Figure 12.1 Comparison of unadjusted ESRD incidence &prevalence worldwide (see page 487 for analytical methods. All rates unadjusted. Data from Argentina (pre-2008), Brazil, Japan, Luxembourg, &Taiwan are dialysis only)
Figure 12.2 Geographic variations in the incidence of ESRD, 2008 (see page 487 for analytical methods. Data presented only for those countries from which relevant information was available. All rates are unadjusted. Data from Bangladesh, Brazil, Czech Republic, Japan, Luxembourg, &Taiwan are dialysis only. Latest data for Hungary are for 2007. Data for France included 18 regions in 2008)
Figure 12.3 Incidence of ESRD, 2008
Table 12.a Incidence of ESRD, by year (per million population) 2003
Incident rates of reported ESRD in 2008 were greatest in Morelos (Mexico), at 557 per million population, followed by Jalisco (Mexico), Taiwan, the United States, and Japan at 400, 384, 362, and 288, respectively. Rates of less than 100 per million were reported in Romania, Finland, the Philippines, Iceland, Russia, and Bangladesh. As stated in previous ADRs, it is important to note the distinction between the incidence of treatment guided by available funding, and the incidence of the disease itself. An affluent nation may allow elderly patients and those with diabetes to receive hemodialysis, for example, while developing nations may restrict their treatment to younger, healthier patients.
Figure 12.3 &table 12.a; see page 487 for analytical methods.
Figure 12.4 Percentage of incident patients with ESRD due to diabetes, 2008
Figure 12.b Percentage of incident patients with ESRD due to diabetes, by year 2003
In 2008, diabetes was the primary cause of ESRD in 59.8, 55.8, and 54.6 percent of new patients in Morelos (Mexico), Malaysia, and Jalisco (Mexico). Hong Kong, Israel, Japan, the Republic of Korea, New Zealand, the Philippines, Taiwan, Thailand, and the United States, all have rates of ESRD incidence due to diabetes of greater than 40 percent. Countries reporting rates below 20 percent include Bosnia and Herzegovina, Iceland, the Netherlands, Norway, Romania, and Russia.
Figure 12.4 &table 12.b; see page 487 for analytical methods.
Data presented only for those countries from which relevant information was available; "." signifies data not reported. All rates are unadjusted. ^UK: England, Wales, &Northern Ireland, age 18+, (Scotland data reported separately). *Data from Bangladesh, Brazil, Czech Republic, Japan, Luxembourg, &Taiwan are dialysis only; Argentina data prior to 2008 are dialysis only. **Latest data for Hungary are 2007. Data for France include 13 regions in 2005, 15 regions in 2006, 18 regions in 2007, &20 regions in 2008.
Figure 12.5 Prevalence of ESRD, 2008
Figure 12.c Prevalence of ESRD, by year (per million population)
Taiwan and Japan continue to report the greatest rates of prevalent ESRD, at 2,311 and 2,126 per million population, respectively, in 2008. The next highest rate is reported by the United States, at 1,752, followed by French-speaking and Dutch-speaking Belgium, at 1,153 and 1,115, respectively. The lowest rates are reported by Bangladesh and the Philippines, at 112 and 110.
Figure 12.5 &table 12.c; see page 487 for analytical methods.
Data presented only for those countries from which relevant information was available; "." signifies data not reported. All rates are unadjusted. ^UK: England, Wales, &Northern Ireland (Scotland data reported separately). *Data from Bangladesh, Brazil, Czech Republic, Japan, Luxembourg, &Taiwan are dialysis only. Argentina data prior to 2008 are dialysis only. **Latest data for Hungary are 2007. Data for France include 13 regions in 2005, 15 regions in 2006, 18 regions in 2007, &20 regions in 2008.
Figure 12.6 Percent distribution of prevalent dialysis patients, by modality, 2008
Table 12.d Percent distribution of prevalent dialysis patients, by modality &year
In Hong Kong, four of five prevalent dialysis patients were treated with CAPD/CCPD in 2008. More than half of prevalent dialysis patients in Jalisco (Mexico) and Morelos (Mexico) use this therapy, as do 36.3 percent of those treated in New Zealand. Hemodialysis remains the most common mode of therapy worldwide; in New Zealand and Australia, however, 15.6 and 9.4 percent of patients, respectively, use home hemodialysis.
Figure 12.6 &table 12.d; see page 487 for analytical methods.
Figure 12.7 Prevalent rates of functioning grafts, 2008
Table 12.e Prevalent rates of functioning grafts, by year (per million population)
Reported prevalent rates of functioning grafts are greatest in Norway, the United States, and Spain, at 572, 545, and 505 per million population in 2008. Countries and regions reporting rates above 400 per million include Austria, Belgium (both French- and Dutch-speaking), Canada, Finland, France, Hong Kong, Jalisco (Mexico), the Netherlands, Scotland, and Sweden. Morelos (Mexico), Romania, Russia, and Thailand report rates below 40 per million population.
Figure 12.7 &table 12.e; see page 487 for analytical methods.
Figure 12.8 Transplant rates, 2008
Table 12.f Transplant rates, by year (per million population)
Norway, the United States, and Jalisco (Mexico) reported transplant rates of 58.3, 57.2, and 54.3 per million population in 2008. Rates are less than 10 per million, in contrast, in Bangladesh, Bosnia and Herzegovina, Malaysia, the Philippines, Romania, Russia, and Thailand.
Figure 12.8 &table 12.f; see page 487 for analytical methods.
Data presented only for those countries from which relevant information was available; "." signifies data not reported. All rates are unadjusted. ^UK: England, Wales, &Northern Ireland (Scotland data reported separately). *Latest data for Hungary are 2007. Data for France include 13 regions in 2005, 15 regions in 2006, &18 regions in 2007 &20 regions 2008.
Figure 12.9 Unadjusted incident rates of ESRD in Asian populations, by age
These figures illustrate trends in ESRD incidence in Asian populations from Taiwan, Japan, and the U.S. Because data are unadjusted, comparisons between countries must be made cautiously. In the future we will develop a common adjustment method to reflect the uniqueness of these countries as well as of the populations within the U.S.
The high rates of ESRD incidence long noted in Taiwan peaked in 2005, and have since declined about 11 percent. For patients age 20–44, rates in the U.S. Asian population are 42 percent higher than in the Taiwanese population; rates in Japan, in contrast, are generally only half as high as those found in U.S. Asians, and have been falling — an important observation, given the country's growing challenges with diabetes and obesity. Among patients age 65 and older, rates differ dramatically — from 803 per million population in Japan to more than 1,900 in Taiwan.
Figure 12.10 Unadjusted incident rates of ESRD in Asian populations, by gender
Figure 12.11 Unadjusted incident rates of ESRD in Asian populations, by primary diagnosis
Rates by primary diagnosis show that ESRD due to glomerulonephritis continues to decline among Asian patients, possibly reflecting their near universal treatment with ACEs/ARBs. It is important to recognize that glomerular diseases are the second leading cause of ESRD in most Asian patients (hypertension holds that rank for white patients in the U.S.). Rates of ESRD due to diabetes, in contrast, appear to be rising in all three Asian populations, an issue of great public health concern. Public health surveillance data on awareness, treatment, and control of kidney disease risk factors are needed to determine if progress is being made in blood pressure control, glycemic control, and the control of salt intake and weight. ? Figures 12.9–11; see page 488 for analytical methods. Incident dialysis patients.
Figure 12.12 Unadjusted incident rates of ESRD in indigenous populations, by age
Figure 12.13 Unadjusted incident rates of ESRD in indigenous populations, by gender
Figure 12.14 Unadjusted incident rates of ESRD in indigenous populations, by primary diagnosis
Native populations in Canada, Australia, New Zealand, and the U.S. face considerable public health challenges — obesity, diabetes, and hypertension, limited access to health care, and economic stresses related to high rates of unemployment and poverty. Each country has attempted to increase health care access, but programs have often been difficult to sustain. In the U.S., the Indian Health Service has focused on diabetes and preventive care. Other countries have tried similar approaches with some success, but face limited budgets.
Direct rate comparisons are not possible without knowing the availability of CKD care and dialysis services. In general, however, reported ESRD incidence among indigenous populations in Canada and the U.S. has been falling for those age 45 and older. In the Australian Aboriginal population age 45 and older, in contrast, rates have been rising during the last 20 years; this is also true among New Zealand Maori and Pacific people age 65 and older.
Around the world there has been increasing discussion of moving more dialysis delivery outside the hospital setting, which may increase access. Perhaps more importantly, however, preventive care to reduce the burden of diabetes, hypertension, and obesity is needed across all populations. Many countries have developed early detection and screening programs for diabetes in the native populations, which carry a disproportionate risk of the disease.
While diabetes is the dominant cause of ESRD in these native populations, the trends vary. Rates among Native Americans in the U.S. have been falling since the late 1990s; those of Canadian Aboriginal populations have leveled off and show signs of falling in the last two years. Rates in Australia and New Zealand, in contrast, have been rising.
Figures 12.12–14; see page 488 for analytical methods. Incident dialysis patients.