Definitions
Progressive renal failure should be monitored by changes in
serum creatinine, from which an estimate of renal function
related to age, gender, ethnicity and possibly body weight can
be calculated. The most widely used estimate is the estimated
glomerular filtration rate (eGFR), calculated by the Modification
of Diet In Renal Disease (MDRD) equation, on which the widely
used Kidney Disease Outcomes Quality Initiative (K/DOQI)
classification of chronic kidney disease (CKD) is based.4
The term CRF is difficult to define. Some symptoms may
develop with only modest renal impairment, but failure is probably best defined as occurring when there are severe symptoms
related to uraemia which can be relieved only by RRT. This is
usually when eGFR falls to 15 ml/minute (CKD stage 5). Established renal failure (ERF), also called end-stage renal failure
(ESRF), is the irreversible deterioration of renal function to a
degree that is incompatible with life without RRT, either by dia
lysis or transplantation. Even this is variable: most nephrologists
now tend to dialyse patients at an earlier stage, when eGFR has
fallen to about 815 ml/minute, rather than wait for it to fall to
56 ml/minute as in the past.
Terry Feest
Abstract
Recent studies have shown that the prevalence of chronic renal failure
(CRF) is higher than was widely believed. The prevalence of renal
replacement therapy (RRT) is rising progressively, although the rising
incidence has stabilized in some developed countries. Needs may differ
widely between countries depending on ethnic mix, social deprivation,
prevalence of diabetes, and quality of healthcare. Diabetic nephropathy
is the single most common cause of CRF, leading to over 40% of RRT
in some countries, and will increase significantly in the next decade.
Making a precise renal diagnosis identifies reversible causes, predicts
prognosis, predicts recurrence after transplantation and aids counselling
in familial conditions. Renal failure is less common in children than in
adults, with a different spectrum of causes. Renal failure is common in
developing countries, particularly in tropical areas and in young individuals: secondary glomerular diseases related to infection are common.
RRT is an expensive but effective therapy, which will inevitably consume
increasing resources in the next decade as numbers grow and the growing
proportion of elderly patients and others with co-morbid conditions and
social problems will place greater demands on healthcare resources.
Renal registries
International and national registries provide the largest volume
of data on RRT. There are many registry-based reports containing data on large numbers of patients, which are fairly precise
in terms of diagnosis and incidence. These are not studies of
the incidence of CRF, but of the incidence of treatment of CRF,
and thus, in addition to varying population needs, also reflect
the attitudes of nephrologists and more importantly of primary
care doctors and other physicians towards referral for nephrological opinion and treatment. Clinical thresholds for treatment
are changing: studies of physicians and nephrologists in the last
decades show a liberalization of attitudes.8
MEDICINE 35:8
Year
Country
Age
Definition
NHANES III
19881994
USA
>20
eGFR
CKD stage 3
CKD stages 4 & 5
C&G eCCr
CKD stage 3
CKD stages 4 & 5
eGFR
CKD stage 3
CKD stages 4 & 5
Ausdiab
De Lusignan, et al
2002
2004
>24
Australia
UK
All
% prevalence
4.3%
0.4%
10.9%
0.3%
4.6%
0.2%
eGFR, glomerular filtration rate; CKD, chronic kidney disease; C&G eCCr, estimated creatinine clearance by Cockcroft and Gault method.
Table 1
Racial differences: in the UK and USA, the incidence of initiation of RRT in African-Caribbean and South Asian populations
in any age group is at least 35-times greater than that in a comparable Caucasian population. As these relatively young ethnic
minority populations mature over the next two decades there
will be a significant increase in demand for RRT.9 In some populations, particularly many indigenous American and Australasian
groups, the incidence of ERF is very much higher, largely due to
a combination of the effects of a massive prevalence of diabetes and hypertension.3,10 However, data from London and elsewhere indicate that other renal diseases are also more common
in the African-Caribbean and South Asian populations. Whilst
CRF is more common in areas of social deprivation, this does not
explain the high incidence of CRF in ethnic minorities.11
Causes of CRF
Precise diagnosis of the cause of renal failure is mainly of importance in identifying and treating reversible causes. It also helps
in assessing prognosis and planning for RRT, in assessing the
likelihood of recurrence of primary renal disease after renal transplantation, and in counselling families in which familial conditions,
such as polycystic kidney disease, vesico-ureteric reflux, or Alports
syndrome, occur.
The causes of ESRF in patients starting dialysis in the UK,
Germany, Australasia and three major racial groups in the USA
are listed in Table 2. In a significant percentage of patients the
MEDICINE 35:8
350
300
250
200
150
100
50
1980
1981
1982
1983
1984
1985
1986
1987
1988
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
Year
The annual rates are per million alive in the population in the specified
age range.
Figure 1
439
Males
Females
600
All UK
500
400
Diabetic nephropathy
Diabetic nephropathy is the most common cause of ESRF in
developed countries, constituting 46% in the USA, 41% Japan,
40% New Zealand, 34% Germany, 30% Australia, 18% in the
UK and 15% in Norway. This variation probably reflects both
a variation in the incidence of diabetes and a variation of the
willingness of physicians to offer dialysis to patients with many
diabetic complications. The diabetic ESRF population is increasingly elderly, with type II diabetics outnumbering type I by over
10:1 in some countries.14,15
300
200
100
90+
8588
8084
7579
6574
5559
6064
5054
4549
4044
3539
3034
2529
2024
Glomerulonephritis
Many forms of glomerulonephritis progress to CRF. Despite the
many recent advances in understanding the underlying mechanisms of disease, relatively few forms of glomerulonephritis have
been shown in controlled trials to respond to currently available
therapies.
Age group
Figure 2
UK 2004
Germany
2004
Australia
2004
New Zealand
2004
USA 20002004
White
Diabetes
Glomerulonephritis
Pyelonephritis/
reflux
Polycystic kidney
disease (PKD)
Hypertension
Renovascular
disease
Uncertain
Missing data
Black
Native American
pmp
pmp
pmp
pmp
pmp
pmp
pmp
18.0
10.4
7.0
18.9
10.9
7.4
34.0
12.0
8.0
66.0
23.3
15.5
30.0
25.0
3.0
28.5
23.8
2.9
40.0
24.0
3.0
44.0
26.4
3.3
44.6
8.4
0.6
115.5
21.8
1.6
43.6
7.1
0.1
434.3
70.7
1.0
73.1
7.5
0.4
271.2
27.8
1.5
5.4
5.7
5.0
9.7
7.0
6.7
5.0
5.5
2.8
7.3
1.0
10.0
0.7
2.6
5.5
7.5
5.8
7.9
<4
22.0
42.7
13.0
n.a.
12.4
16.0
n.a.
17.6
21.1
2.6
54.6
6.7
33.8
0.4
336.6
4.0
8.0
0.4
29.7
1.5
23.0
9.2
24.2
9.7
9.0
n.a.
17.5
-!
7.0
n.a.
6.7
-!
5.0
n.a.
5.5
-!
4.5
1.0
11.7
2.6
3.1
1.0
30.9
10.0
2.5
0.2
9.3
0.7
Table 2
MEDICINE 35:8
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Practice points
Numbers of patients on renal replacement therapy are
rising, with an increasing proportion elderly: this has major
implications for resources
The incidence of CRF increases with age and is at least threeto five-fold higher in many ethnic minority populations
Making a precise renal diagnosis identifies reversible causes,
predicts prognosis, predicts recurrence after transplantation
and aids counselling in familial conditions
Renal failure is less common in children than in adults and
the spectrum of causes differs
References
1 Feest TG, Rajamahesh J, Byrne C, et al. Trends in adult renal
replacement therapy in the UK: 19822002. QJM 2005; 98: 2128.
2 Ansell D, Feest T, Rao R, Williams A, Winearls C. UK Renal Registry
8th Annual Report. 2005. (Available at: www.renalreg.com)
3 US Renal Data System. USRDS 2006 Annual Data Report: Atlas of
end-stage renal disease in the United States. USRDS, 2006.
(Available at: www.usrds.org)
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