Pam Harrison

May 26, 2016

VIENNA — The need for renal replacement therapy has stabilized in many parts of the Western world, new registry data show.

"There was a continuous increase in the incidence of renal replacement therapy from the 1980s until the early 2000s, and every report from that period predicted ongoing growth because of the epidemic of diabetes, hypertension, and aging populations," said Vicky De Meyer, MD, from Antwerp University Hospital in Edegem, Belgium.

"But when we looked at all the data combined, we saw a clear-cut decline in incidence in the age categories of 65 to 74 years and 75 years and older," she reported. There was also a decline in incidence in people with diabetic nephropathy, she added.

"Starting dialysis with a lower estimated glomerular filtration rate [eGFR], more conservative therapy for older patients, and better diabetes control could all contribute to these findings," she explained.

The study results were presented here at the European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 53rd Congress

Different Registry Data

Dr De Meyer and her colleagues examined data from the ERA-EDTA registry, which covers Austria, Belgium, Denmark, Finland, Greece, the Netherlands, Norway, and Sweden, from 1989 to 2012; the US Renal Data System (USRDS) from 1980 to 2012; the Canadian Organ Replacement Registry from 1993 to 2012; and the Australia and New Zealand Dialysis and Transplant Registry from 1992 to 2012.

The incidence rate of renal replacement therapy was substantially higher in the United States than in any other country.

"There was a continuous increase in incidence from 1980 to 2006 in the United States, after which rates stabilized, hit a small peak in 2009, and then stabilized again," Dr De Meyer reported. "And the trend is continuing."

Although the incidence of renal replacement therapy was significantly lower in New Zealand and Australia than in the United States, the same increase in incidence was seen, up to about 2001 for New Zealand and 2006 for Australia, after which the need to treat end-stage renal disease stabilized.

"The pattern was a bit different for Canada," Dr De Meyer explained. As in other countries, the incidence increased up until about 2006, after which it stabilized, and then declined from about 2009 onward.

"The same was true for Austria, where we saw an increase until 2004, after which we saw a decline," she added.

 
It is encouraging to see that many countries have three times fewer dialysis patients than the United States.
 

The incidence has consistently been much lower in the Scandinavian than in other countries, and rates there have remained relatively stable since 1998.

"It is encouraging to see that many countries have three times fewer dialysis patients than the United States. It means that their populations are leading healthier lives — no smoking, better diabetes and hypertension control, doing more sports, not being obese," said senior researcher Daniel Abramowicz, MD, PhD, from Antwerp University in Belgium.

"What we are seeing in the northern countries in Europe is reassuring. This is the target that countries with a high incidence of dialysis should follow because it is achievable," he told Medscape Medical News.

Need to Plan Ahead

It is important that healthcare planners are aware of incidence trends in their countries so that the size and number of dialysis units can be adjusted accordingly, Dr De Meyer told Medscape Medical News.

"This analysis provided us with a measure of quality control as well," she said. "If you find you need less renal replacement therapy, maybe you're doing a better job at managing patients overall."

But the prominent decrease in the use of renal replacement therapy in older patients seen in this analysis might simply reflect an increase in more conservative treatment, without dialysis, of older patients with end-stage renal disease, Dr Abramowicz pointed out.

"There are data that indicate that starting dialysis in older patients may not lengthen their lives, so it's not true that dialysis increases longevity," he explained.

The IDEAL trial confirmed this. It showed no difference in mortality between patients who started dialysis early, when their eGFR was 10 to 14 mL/min per 1.73 m², and those who started later, when their eGFR dropped to 5 to 7 mL/min per 1.73 m² (Nephrol Dial Transplant. 2011;26:2082-2086).

Moreover, data suggest that the best days for patients with end-stage renal disease are dialysis-free days, so staying off dialysis, even if there is some trade-off in terms of longevity, is likely to be associated with a better quality, if not quantity, of life, Dr De Meyer pointed out.

And the conservative treatment of patients with even very advanced end-stage renal disease can extend life significantly, said Dr Abramowicz.

"With renal disease, you get anemia, which can be treated with erythropoietin; you get fluid overload, but you can optimize your diuretic to treat that; and patients need to pay attention to their diet and not eat too much salt or protein because protein leads to acidosis," he explained.

"There are many ways not to dialyze the patients. It won't change their eGFR, but it will modulate the complications of very advanced chronic renal failure," he added.

Renal Replacement Therapy in the United States

Data from the USRDS show that the entire increase in the prevalence counts of dialysis from 1980 to 2006 was due to patients who had an eGFR above 10 mL/min per 1.73 m², said Richard Glassock, MD, from the University of California, Los Angeles School of Medicine.

"If you eliminate this group of patients, growth in the prevalence counts would have been absolutely stable over that time period," he told Medscape Medical News.

"If there is a systematic change in attitudes about when dialysis starts and patients are held on conservative therapy for a longer period of time, there will be an expected decline in the incidence rates of renal replacement therapy," he said. But that "decline will dissipate over time."

In fact, over the past few years, there has been a downward trend in the use of renal replacement therapy in the United States, Dr Glassock reported.

He said he doesn't think there will be an explosion in the need to treat end-stage renal disease as the baby boomers reach old age, as some have predicted.

"Cardiovascular disease doesn't kill us as frequently as it used to. We're doing a lot better with diabetic nephropathy, so patients are progressing less frequently to end-stage renal disease, and we have better medications for diabetes, so diabetes control has improved dramatically," he explained.

"Extrapolating from previous data to future data, based on just the fact that the population is going to get older in most Westernized countries, does not necessarily mean that there will be second bubble in the treatment of end-stage renal disease," he pointed out.

Dr De Meyer, Dr Abramowicz, and Dr Glassock have disclosed no relevant financial relationships.

European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 53rd Congress: Abstract MO031. Presented May 23, 2016.

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