Epidemiology of end-stage kidney disease

End-stage kidney disease (ESKD) is a common and morbid disease that affects patients’ quality and length of life, representing a large portion of health care expenditure in the United States. These patients commonly have associated diabetes and cardiovascular disease, with high rates of cardiovascular-related death. Management of ESKD requires renal replacement therapy via dialysis or transplantation. While transplantation provides the greatest improvement in survival and quality of life, the vast majority of patients are treated initially with hemodialysis. However, outcomes differ significantly among patient populations. Barriers in access to care have particularly affected at-risk populations, such as Black and Hispanic patients. These patients receive less pre-ESKD nephrology care, are less likely to initiate dialysis with a fistula, and wait longer for transplants—even in pediatric populations. Priorities for ESKD care moving into the future include increasing access to nephrology care in underprivileged populations, providing patient-centered care based on each patient’s “life plan,” and focusing on team-based approaches to ESKD care. This review explores ESKD from the perspective of epidemiology, costs, vascular access, patient-reported outcomes, racial disparities, and the impact of the COVID-19 crisis.     

Hemodialysis Disparities in African Americans: The Deeply Integrated Concept of Race in the Social Fabric of Our Society

End‐stage renal disease (ESRD) is one of the starkest examples of racial/ethnic disparities in health. Racial/ethnic minorities are 1.5 to nearly 4 times more likely than their non‐Hispanic White counterparts to require renal replacement therapy (RRT), with African Americans suffering from the highest rates of ESRD. Despite improvements over the last 25 years, substantial racial differences are persistent in dialysis quality measures such as RRT modality options, dialysis adequacy, anemia, mineral and bone disease, vascular access, and pre‐ESRD care. This report will outline the current status of racial disparities in key ESRD quality measures and explore the impact of race. While the term race represents a social construct, its association with health is more complex. Multiple individual and community level social determinants of health are defined by the social positioning of race in the U.S., while biologic differences may reflect distinct epigenetic changes and linkages to ancestral geographic origins. Together, these factors conspire to influence dialysis outcomes among African Americans with ESRD.     

Inequalities in access to pediatric ESRD care: a global health challenge

The increasing attention paid to chronic kidney disease (CKD) as a major cause of mortality and disability, as well as the advances in management of CKD in children, have created a growing demand for pediatric renal replacement therapy (RRT) worldwide. A study by Koch Nogueira and colleagues of children on the transplant waiting list showed large disparities in access to pediatric kidney transplantation between regions in Brazil. This finding raises a wider question about inequalities in access to CKD care in children. Here we review the available data on the global burden of end-stage renal disease in children, the need for pediatric RRT, and its actual provision worldwide. We focus on inequalities in access to renal care for children that currently exist between and within countries. Reduction in worldwide inequalities in access to RRT in children remains a challenge, which requires greater awareness and effective interventions and policies.     

When ESKD complicates disease management: GI bleeding and other GI illnesses

The presentation of gastrointestinal (GI) illnesses is similar in patients with end-stage kidney disease (ESKD) and in the general population. However, there are several instances where kidney failure and renal replacement therapy (RRT) can affect the course of the disease and its management. In this section, we will focus on unique factors of GI illnesses that should be considered in the ESKD population with and without residual kidney function (RKF). We will also discuss the role of RRT modalities in the occurrence and treatment of GI disease.     

So you need to start renal replacement therapy on your ICU patient?

Critical care physicians will increasingly encounter patients with both acute and chronic renal failure that will necessitate initiation or continuation of renal replacement therapy (RRT) whilst in the Intensive Care Unit (ICU). A clear understanding of the principles involved and outcome data associated with increasingly diverse area of RRT modalities is essential to attain optimal patient care. This article commences with a revision of the principles of dialysis and ultrafiltration, currently available modalities of RRT and indications for their commencement. Prevention strategies to avoid initiation of RRT are outlined, followed by a practical discussion of issues such as selection of a modality, dosing, filter selection, anticoagulation, vascular access, choice of fluids and other considerations, for when RRT must be commenced.     

Increases in renal replacement therapy in Australia and New Zealand: understanding trends in diabetic nephropathy

Aim: The incidence of end‐stage kidney disease (ESKD) has been increasing worldwide, with increasing numbers of older people, people with diabetic nephropathy and indigenous people. We investigated the incidence of renal replacement therapy (RRT) in Australia and New Zealand (NZ) to better understand the causes of these effects. Methods: Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA)registry and relevant population data were used to investigate the incidence of RRT in five demographic groups: Indigenous and non‐indigenous Australians, Māori, Pacific Islanders and other New Zealanders, as well as differences between genders and age groups. Results: The numbers of patients commencing RRT each year increased by 321% between 1990 and 2009. This increase was largely driven by increases in patients with diabetic nephropathy. In 2009 35% of new patients had ESKD resulting from diabetic nephropathy 92% of which were type 2. Indigenous Australians, and Māori and Pacific people of NZ have elevated risks of commencing RRT due to diabetic nephropathy, although the risks compared with non‐indigenous Australians have decreased over time. A small element of lead time bias also contributed to this increase. Males are more likely to commence RRT due to diabetes than females, except among Australian Aborigines, where females are more at risk. There is a marked increase in older, more comorbid patients. Conclusions: Patterns of incident renal replacement therapy strongly reflect the prevalence of diabetes within these groups. In addition, other factors such as reduced risk of dying before reaching ESKD, and increased acceptance of older and sicker patients are also contributing to increases in incidence of RRT.     

Birth cohort effects in incident renal replacement therapy in Japan, 1982–2021

Clinical and Experimental Nephrology - This study aimed to investigate the long-term trends of incident end-stage kidney disease (ESKD) requiring renal replacement therapy (RRT) in Japan using...     

Prevention of renal disease progression and renal replacement therapy in emerging countries

Chronic kidney disease is increasing in both developed and emerging countries with progressive encroachment on health services budgets. In spite of the lack of accurate registries, we tried to focus on the magnitude of the problem on different continents. Prevention of progression has been a remote but reachable goal. Many health foundations including the International Society of Nephrology gave recommendations for prevention and slowing progression, but these are again confronted by lack of resources. Integration of governmental, community, and expert efforts is necessary to set prevention priorities including affordable screening programs and increasing access to renal replacement therapy by different modalities.     

Outcome of dialysis in children with human immunodeficiency virus infection

Human immunodeficiency virus (HIV) infection accounts for an unknown percentage of children with end-stage kidney disease (ESKD). Our objective was to compare the outcome of renal replacement therapy (RRT) in subjects with ESKD due to HIV and other diagnoses and to examine the prevalence of ESKD due to HIV. We analyzed Kt/V, morbidity, mortality, echocardiography, nutritional, and transplant status in 12 dialysis patients with HIV and 32 without HIV followed at our center between February 2002 and February 2007. Body mass index (BMI) was lower and Kt/V higher in HIV than in non-HIV patients. Shortening fraction was significantly lower in HIV patients. There were six deaths in the HIV group and one in the non-HIV group over the study period. Hemodialysis (HD) is the prevalent mode of RRT in HIV in urban settings, and its adequacy as measured by Kt/V was higher in HIV patients than in non-HIV patients. Decreased BMI and cardiovascular disease may be associated with increased mortality in children with HIV on RRT.     

Frequency,etiology and treatment of childhood end-stage kidney disease in Australia and New Zealand

To describe the trends in end-stage kidney disease (ESKD) in children in Australia and New Zealand over time and across different ages, we analyzed data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA). A total of 1,485 children aged less than 18 years received renal replacement therapy (RRT) during the period from 1963 to 2006, of which children 55.6% were male. The incidence of ESKD increased over the first two decades but has been stable at 8 per million since the mid-1980s. The prevalence of ESKD continues to increase in all age groups, especially among older children, and is currently 50 per million in those aged less than 18 years. The cause of ESKD over the entire cohort was one-third each for glomerulonephritis (32.5%), structural anomalies (hypoplasia/dysplasia, posterior urethral valves or reflux nephropathy, 35.8%), and cystic disease or other conditions (31.7%). Proportionately, glomerulonephritis is becoming less common. Overall, 50% of children were commenced on peritoneal dialysis as the initial RRT modality, 30% were started on hemodialysis, and 20% underwent transplantation pre-emptively. The proportion of children receiving transplants has not increased over time.     

Nephrology in Latin America,with special emphasis on Brazil

Latin America constitutes a complex universe that shows extreme variation regarding socioeconomic and human development. Brazil is the largest and most populous Latin American country, and combines characteristics encountered in developed countries with problems typically associated with the poorest regions of the world. These disparities condition the profile of renal disease in Brazil, with glomerulonephritis still the leading cause of ESRD. Little is known about the epidemiology of renal disease in the Brazilian (or Latin American) native population, which is numerous in some Central and South American countries, but constitute a very small minority in Brazil. However, interesting information has been obtained from the Yanomamis, a tribe living in Northern Brazil and Southern Venezuela. Hypertension is virtually absent among these people, who ingest very little sodium, lending strong support to the concept that sodium retention, a "civilization" factor, plays a role in the pathogenesis of arterial hypertension. Despite Brazil's striking socioeconomic disparities, access to RRT is in principle accessible to all those in need of it. The dialysis units have been modernized in recent years, whereas the Government covers most expenses related to RRT. However, the prevalence of RRT in Brazil is currently approximately 320 per million population, less than one third as high as in the US, suggesting that ESRD may be underdiagnosed in the country. Much effort is still needed to limit the prevalence of renal disease and to improve the quality and the reach of RRT in Brazil and in Latin America.     

Disparities in end-stage renal disease care in South America

South America is one of the most heterogeneous regions in the world regarding ethnical composition and socioeconomic development level. Our aim was to analyze the status of end-stage renal disease (ESRD) management in the Portuguese-speaking and Spanish-speaking countries of South America. Data were collected using a survey sent to the Society of Nephrology of each country, and complemented with data available in the Latin American Dialysis and Transplant Registry or personal communication with collaborators within the nephrology societies. Most of South America countries have a hybrid of public and private healthcare system. Universal access to renal replacement therapy (RRT) is provided in Argentina, Brazil, Chile, Uruguay and Venezuela which comprise nearly 73% of South America population. The expenditure on health per capita varies from nearly US$ 200 per year in Bolivia to more than US$ 1,600 per year in Argentina. The prevalence of patients on RRT varies from 95 pmp. in Paraguay and 924 pmp in Chile. There is an important association between the prevalence of diabetes and the number of patients on RRT. Older people also are at a higher risk of developing ESRD. The rapid aging of the population and a higher prevalence of diabetes will probably translate into a burden of ESRD in the future. It is to be hoped that political and economical stability in the region can ease the adoption of universal access to ESRD treatment in all South American countries.     

Unnecessary Renal Replacement Therapy for Acute Kidney Injury is Harmful for Renal Recovery

The use of renal replacement therapy (RRT) for severe acute kidney injury (AKI) is frequently necessary in the face of life‐threatening complications; however, there is wide practice variation with respect to triggers for RRT initiation. Recent evidence suggests that RRT may be independently associated with impaired recovery following AKI. There are plausible mechanistic reasons why RRT may be harmful and this concept is supported by ancillary evidence in the form of studies that have assessed the impact of different modalities of RRT for AKI as well as some of the literature pertaining to initiation of chronic hemodialysis in end‐stage kidney disease patients (ESKD). As such, avoiding unnecessary RRT (URRT) is a desirable goal. There is emerging evidence of strategies that may be effective to help limit URRT. These strategies primarily involve early identification of AKI and limiting iatrogenic harm once AKI is established. Further research into defining and preventing URRT may help improve the consistently poor outcomes following severe AKI with respect to development of chronic kidney disease and ESKD.     

Nationwide survey of adolescents and young adults with end-stage kidney disease

Aim: To better understand the health‐care needs of adolescents and young adults (AYA) with end‐stage kidney disease (ESKD), we sought to describe the demographic characteristics of a national cohort. Methods: Data were retrieved from the Australia and New Zealand Dialysis and Transplant Registry. We included all patients aged 15–25 years, living in Australia and receiving renal replacement therapy (RRT) on 31 December 2009. Data included race, aetiology of kidney disease, postal code, transition and migration history. Results: A total of 495 AYA were receiving RRT in Australia giving a prevalence of 143 per million age‐related population. Sixty‐three per cent had a functioning transplant, 24% were receiving haemodialysis and 13% peritoneal dialysis. Median current age was 22 years (interquartile range (IQR) 19–24). The most prevalent cause of ESKD was glomerulonephritis (33%). The majority of patients lived in capital cities. Indigenous patients were more likely to live in more remote areas. Eighty‐five per cent of patients were currently receiving care at an adult unit and 35% of these patients had transitioned from a paediatric unit since starting RRT. The median number of patients per adult unit was 5 (IQR 3–10). Conclusions: The majority of Australian AYA with ESKD are managed in adult units; however, the number at any one unit is low. As most live in the capital cities there may be an opportunity to establish centralized services designed to cater for the needs of AYA patients. However, the needs of patients living in more remote areas, including a significant proportion of Indigenous patients, may not be met by such a model.     

End-Stage Renal Failure and National Resources: The Brazilian Experience

Brazil is the fifth largest and the fifth most populous nation in the world. Its economy rivals Mexico as the strongest in Latin America and ranks among the 15 largest economies in the world. Despite these achievements, a substantial fraction of the Brazilian population still lives in poverty, and many still have limited access to medical assistance. There are currently about 380 patients on hemodialysis per million populations (pmp), approximately one third of the U.S. prevalence, suggesting that a large fraction of end-stage renal disease (ESRD) patients are not diagnosed and treated properly. In Brazil, access to renal replacement therapy (RRT), including renal transplantation, is universal, and the corresponding costs, including those of medications (immunosuppressors and treatment of ESRD complications), are covered by the Brazilian government. However, given the continuous growth of the ESRD population and of the costs incurred by RRT, the efficacy and reach of this system may be severely limited in years to come. In the current struggle against the ESRD epidemics, the Brazilian medical community and health authorities face a triple challenge: to limit the incidence of renal disease, slow or detain the progression of established chronic nephropathies, and ensure that access to quality RRT remains granted to all those who, despite all efforts, reach ESRD.     

End-stage renal failure and national resources: the Brazilian experience

Brazil is the fifth largest and the fifth most populous nation in the world. Its economy rivals Mexico as the strongest in Latin America and ranks among the 15 largest economies in the world. Despite these achievements, a substantial fraction of the Brazilian population still lives in poverty, and many still have limited access to medical assistance. There are currently about 380 patients on hemodialysis per million populations (pmp), approximately one third of the U.S. prevalence, suggesting that a large fraction of end-stage renal disease (ESRD) patients are not diagnosed and treated properly. In Brazil, access to renal replacement therapy (RRT), including renal transplantation, is universal, and the corresponding costs, including those of medications (immunosuppressors and treatment of ESRD complications), are covered by the Brazilian government. However, given the continuous growth of the ESRD population and of the costs incurred by RRT, the efficacy and reach of this system may be severely limited in years to come. In the current struggle against the ESRD epidemics, the Brazilian medical community and health authorities face a triple challenge: to limit the incidence of renal disease, slow or detain the progression of established chronic nephropathies, and ensure that access to quality RRT remains granted to all those who, despite all efforts, reach ESRD.     

Advances in pediatric renal replacement therapy for acute kidney injury

The disease spectrum leading to pediatric renal replacement therapy (RRT) provision has broadened over the last decade. In the 1980s, intrinsic renal disease and burns comprised the most common pediatric acute renal failure etiologies; more recent data demonstrate that pediatric acute kidney injury (AKI) most often results from complications of other systemic diseases resulting from the advancements in congenital heart surgery, neonatal care, and bone marrow and solid organ transplantation. In addition, RRT modality preferences to treat critically ill children have shifted from peritoneal dialysis to continuous renal replacement therapy (CRRT) as a result of improvements in CRRT technologies. In this article, we aim to review the pediatric specific causes for RRT provision, emphasizing the emerging practice patterns with respect to modality and timing of treatment. We will focus on the application of different RRT modalities and related outcome of children with AKI who receive RRT.     

The epidemiology of end-stage renal disease in Nigeria: the way forward

The incidence of CKD (Chronic kidney disease) in Nigeria has been shown by various studies to range between 1.6 and 12.4%. We have shown that the burden of renal disease in Nigeria is probably significantly higher than any previous study on end-stage renal disease (ESRD) has documented, as most studies are hospital-based and fail to include the many patients who do not have access to hospital care. The increased prevalence of ESRD among blacks in the United States and South Africa compared with other races also suggests that ESRD may be more prevalent in Africa than in the United States and other developed nations. Common causes of CKD in Nigerian adults are glomerulonephritis and hypertension, while common causes in children are glomerulonephritis and posterior urethral valves. In the United States, diabetes and hypertension are the commonest causes of CKD and glomerulonephritis plays a less important role. Access to renal replacement therapy (RRT) in Nigeria is limited, and mortality rates are very high, ranging between 40 and 50%. Important steps towards improving the situation are the development of prevention programmes and increased funding to ensure increased availability of RRT. To achieve this, health policies concerning CKD must be formulated, and the lack of a renal registry makes it difficult for this to be done. There is need for the development of a functional organizational structure for the reporting of CKD in Nigeria, the Nigerian Renal Registry.     

Impact of renal disease in cardiovascular surgery: emphasis on the African-American patient

Cardiovascular disease remains a significant source of morbidity and mortality for patients with kidney disease. Coincident with the development of chronic renal failure, patients typically manifest a systemic vasculopathy often involving the cardiovascular system. The renal failure patient is also plagued by multiple comorbid conditions that may adversely affect cardiovascular outcomes. Consistent with the national trend of increasing numbers of patients requiring renal replacement therapy (RRT), patients requiring invasive cardiovascular procedures are also on the incline. The morbidity and mortality related to these procedures has remained high despite significant advances in delivery and maintenance of care. Is the African-American patient with renal failure unique in terms of cardiovascular morbidity and mortality? Numerous studies have documented racial differences in access to invasive cardiovascular procedures, even after controlling for multiple physiologic risk factors and socioeconomic and sociocultural factors. Studies have also shown higher morbidity and lower survival for African-American patients after cardiac procedures. In this high-risk population these same issues perhaps would persist. The following paper will examine the current status of cardiovascular disease in the renal failure patient with emphasis on the African-American patient population.