Impacto ERC 2015 Venezuela

IMPACTO
ERC 2015
DIEGO L. GARCIA, MD
L.D. Byham-Gray et al. (eds.), Nutrition in Kidney Disease, Second Edition, Nutrition and Health, Springer Science New York 2014
Incidence rate of ESRD, per million population, by

country, in 2012
Data presented only for countries from which relevant information was
available. All rates are unadjusted. ÛK: England, Wales, & Northern Ireland
(Scotland data reported separately). Japan and Taiwan are dialysis only. Data
for Belgium do not include patients younger than 20. Data for Indonesia
represent the West Java region. Data for France include 22 regions. Data for
Spain include 18 of 19 regions.
USRDS 2014
Temporal trends in the incidence rate of ESRD, per

million population, by country, years 2000-2012
(B) Countries in which the incidence rate of ESRD decreased at least 3% from
2006-2012
Data source: Special analyses, USRDS ESRD Database.

All rates are unadjusted. Data are shown for countries
with incidence increase or decrease from 2006 to 2012
or 2011. Data for U.S. are shown for comparison
purposes. Abbreviations: ESRD, end-stage renal disease.
USRDS 2014
DIALISIS
DIALISIS
CAMBIO (%)
24000
22300
12.24
22926
23816
14.00
20624
19550
18000
17544
10.50
17157
7.52
Nmero
7.00
5.21
12000
%
3.74
3.50
2.73
6000
0.00
-2.26
0
-3.50
2008
2009
2010
2011
2012
2013
2014
Prevalence of dialysis, per million population, by

country, in 2012
Data source: Special analyses, USRDS ESRD Database. All rates are unadjusted and reflect prevalence at
the end of 2012. Japan and Taiwan include dialysis patients only. ÛK: England, Wales, & Northern
Ireland (Scotland data reported separately). Data for Spain include 18 of 19 regions. Data for France
include 22 regions. Data for Belgium do not include patients younger than 20. Abbreviations: sp.,
speaking.
USRDS 2014
Distribution of the percentage of prevalent dialysis patients

using in-center HD, home HD, and CAPD/CCPD, in 2012
Data source: Special analyses, USRDS ESRD Database. Denominator is calculated as the sum of patients receiving HD, PD, and Home HD;
does not include patients with other/unknown modality. ÛK: England, Wales, & Northern Ireland (Scotland data reported separately).
Data for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Indonesia represent the West Java region. Data for
Belgium do not include patients younger than 20. Abbreviations: CAPD, continuous ambulatory peritoneal dialysis; CCPD, continuous
cycling peritoneal dialysis; ESRD, end-stage renal disease; HD, hemodialysis; PD, peritoneal dialysis; sp., speaking.
USRDS 2014
Kidney transplantation rate, per million population,

by country, in 2012
Data source: Special analyses, USRDS ESRD Database. Data

presented only for countries from which relevant information
was available. All rates are unadjusted. ÛK: England, Wales,
& Northern Ireland (Scotland data reported separately). Data
for Belgium do not include patients younger than 20. Data for
France include 22 regions. Data for Spain include all regions.
There is underreporting of prevalent transplant patients in
Turkey. Abbreviations: sp., speaking.
USRDS 2014
Percentage of incident ESRD patients with diabetes

as the primary ESRD cause, by country, in 2012
Colombia 42.5%
Data source: Special analyses, USRDS ESRD Database. Data presented only for countries from which relevant
information was available. ÛK: England, Wales, & Northern Ireland (Scotland data reported separately). Data
for Spain include 18 of 19 regions. Data for France include 22 regions. Data for Indonesia represent the West
Java region. Data for Belgium do not include patients younger than 20. There were zero ESRD patients in Iceland
with diabetes as the primary ESRD cause in 2012. Abbreviations: ESRD, end-stage renal disease; sp., speaking.
USRDS 2014
IDF 2014: AMRICA LATINA (estimados)

Prevalencia Muertes Costo por
Muertes 1 de cada X
Casos de
Prevalencia comparativ relacionada
TRR en la
diabetes no
persona con relacionada
adultos
ERC 3-5 en
nacional de
vida (2%) en
a de
s
s con la
diagnostica
diabetes
tiene
miles (25%)
diabetes (%) diabetes
miles
con la
diabetes < diabetes
da en miles
(USD)
(%)
diabetes
60 aos (%)
451,7
6,0
5,7
15221
1422,7
39,3
17
406,52
32,52
Poblacin
adulta
(20-79) en
miles
Casos de
diabetes
en miles
Argentina
27236,1
1626,1
Bolivia
5890,1
371,1
103,1
6,3
7,3
4694
252,1
50,5
16
92,77
7,42
Brazil
133879,9
11623,3
3229,0
8,7
8,7
116383
1527,6
41,7
12
2905,83
232,47
Chile
12287,5
1513,4
325,5
12,3
11,2
8956
1427,0
35,6
378,35
30,27
Colombia
30581,7
2191,9
608,9
7,2
7,3
14168
805,0
55,5
14
547,98
43,84
Costa Rica
3298,2
305,7
84,9
9,3
9,5
1590
1364,4
45,2
11
76,43
6,11
Cuba
8395,4
702,4
195,1
8,4
6,7
5921
704,7
31,3
12
175,60
14,05
Dominicana
6239,6
669,9
186,1
10,7
11,4
7888
466,0
64,1
167,46
13,40
Ecuador
9539,2
544,4
151,2
5,7
5,9
4541
562,5
65,9
18
136,10
10,89
El Salvador
3667,8
386,8
107,5
10,6
11,8
3676
377,3
48,7
96,70
7,74
Guayana Fr
148,4
12,1
3,4
8,2
8,5
12
3,03
0,24
Guatemala
7618,0
680,0
188,9
8,9
10,8
7965
385,4
61,0
11
170,00
13,60
Honduras
4414,5
420,8
116,9
9,5
11,7
2774
319,7
59,9
10
105,20
8,42
Mexico
75686,3
9018,6
2254,7
11,9
12,6
68660
892,5
42,0
2254,65
180,37
Nicaragua
3451,3
356,1
98,9
10,3
12,5
3167
221,3
54,7
10
89,02
7,12
Panama
2417,1
202,2
56,2
8,4
8,5
1397
1096,2
42,1
12
50,54
4,04
Paraguay
3930,9
243,8
67,7
6,2
7,0
2242
658,2
45,2
16
60,94
4,88
Peru
18745,2
1143,6
317,7
6,1
6,5
7650
523,5
53,0
16
285,90
22,87
Puerto Rico
2562,2
397,1
110,0
15,5
13,0
99,28
7,94
Uruguay
2282,6
150,3
32,3
6,6
5,8
1040
1742,1
33,5
15
37,56
3,01
Venezuela
19035,6
1252,4
347,9
6,6
6,9
9778
935,5
53,1
15
313,11
25,05
TOTAL
381307,3
33811,9
9037,6
8,7
9,0
287710
825,5
48,5
12
8452,98
676,24
Pas

La Creciente Carga Global de ERC
Diabetic CKD: A Growing Global Disease Population

55% Projected Prevalence Increase by 2035
600
552
450
366
= current total population

of UK, France, and Spain5
300
165.6
150
109.8
2013
2035
Global Diabetes Population1-3
2013
2035
Projected Cases of Diabetic CKD1-4*
*Early diabetic CKD defined as albumin excretion rate of 20-200 g/min or 30-300 mg/24 h, or a spot urine albumin-to-creatinine ratio of 30-300 mg/g
(3.5-35 mg/mmol) in males and 20-200 mg/g (2.5-25 mg/mmol) in females. Diabetic CKD is marked by proteinuria >500 mg/24 h or albuminuria >300 mg/24
h. Decreased estimated glomerular filtration rate <60 ml/min/1.73 m2 may be another manifestation of diabetic CKD.4
1. International Diabetes Federation. IDF Diabetes Atlas. 6th ed. http://www.idf.org/diabetesatlas. Published 2013. Accessed January 2, 2014. 2. Schieppati A,
Remuzzi G. Chronic renal diseases as a public health problem: epidemiology, social, and economic implications. Kidney Int. 2005;68(suppl 98):S7S10. 3. Parving H-H, Mauer M,
Fioretto P, Rossing P, Ritz E. Diabetic nephropathy. In: Taal MW, Chertow GM, Marsden PA, Skorecki K, Yu ASL, Brenner BM, eds. Brenner & Rectors The Kidney. 9th ed. Philadelphia, PA:
Elsevier/Saunders; 2012:1411-1454. 4. Reutens AT, Atkins RC. Epidemiology of diabetic nephropathy. Contrib Nephrol. 2011;170:1-7.5. Central Intelligence Agency. CIA World Factbook
website. https://www.cia.gov/library/publications/the-world-factbook. Accessed January 2, 2014.
Reduced eGFR, Albuminuria, and Risk of Mortality in

General Population
All-cause mortality; eGFR
HR (95% CI)
HR (95% CI)
0.5
0.5
15
30
45
60
75
90
105
2.5
(0.3)
120
eGFR (mL/min/1.73 m2)
Cardiovascular mortality; eGFR
5
(0.6)
10
(1.1)
30
(3.4)
ACR (mg/g [mg/mmol])
300
(33.9)
1000
(113.0)
Cardiovascular mortality; ACR
HR (95% CI)
HR (95% CI)
0.5
All-cause mortality; ACR
15
30
45
60
75
90
105
120
Reprinted from The Lancet, with permission from Elsevier
0.5
2.5
(0.3)
5
(0.6)
10
(1.1)
30
(3.4)
ACR (mg/g [mg/mmol])
300
(33.9)
eGFR=estimated glomerular filtration rate; HR=hazard ratio; CI=confidence interval; ACR=albumin-to-creatinine ratio.
Matsushita K, Van der Velde M, Astor BC, et al; Chronic Kidney Disease Prognosis Consortium. Association of estimated glomerular filtration rate and
albuminuria with all-cause cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073-2081.
1000
(113.0)
Reduced eGFR, Albuminuria, and Risk of Mortality in

General Population
Cardiovascular mortality; ACR studies
16
16
HR (95% CI)
HR (95% CI)
All-cause mortality; ACR studies
2
1
0.5
2
1
15
30
45
60
75
33.9 mg/mmol (300 mg/g)
90
105
120
0.5
15
30
3.4-33.8 mg/mmol (30-299 mg/g)
eGFR=estimated glomerular filtration rate; HR=hazard ratio; CI=confidence interval; ACR=albumin-to-creatinine ratio.
45
60
75
90
105
120
<3.4 mg/mmol (<30 mg/g)
Matsushita K, Van der Velde M, Astor BC, et al; Chronic Kidney Disease Prognosis Consortium. Association of estimated glomerular filtration rate and
albuminuria with all-cause cardiovascular mortality in general population cohorts: a collaborative meta-analysis. Lancet. 2010;375(9731):2073-2081.
Risk of Albuminuria, Elevated Creatinine, and Death in

Patients With Type 2 Diabetes
The United Kingdom Prospective Diabetes Study: Newly diagnosed, predominantly white, medically treated
(N=5,097)*
No albuminuria
1.4%
per year
2.0% per year

Microalbuminuria
50-299 mg/L
3.0%
per year
2.8% per year

Macroalbuminuria
300 mg/L
4.6%
per year
2.3% per year

*Median patient
follow-up was
10.4 years.
Elevated plasma creatinine
175 mol/L (1.98 mg/dl)
or RRT
D
E
A
T
H
19.2%
per year
Reprinted with permission from Macmillan Publishers
RRT=renal replacement therapy.

Adler AI, Stevens RJ, Manley SE, Bilous RW, Cull CA, Holman RR; UKPDS Group. Development and progression of nephropathy in type 2 diabetes: the United Kingdom Prospective Diabetes Study
(UKPDS 64). Kidney Int. 2003;63(1):225-232.
Prognosis for Dialysis Patients With Diabetes Is Worse Than

That For Dialysis Patients Without Diabetes
Prostate cancer
Thyroid cancer
Breast cancer
Hodgkin lymphoma
Bladder cancer
Non Hodgkin lymphoma
Kidney cancer
Colorectal cancer
Leukemia
Long-term dialysis
Myeloma
Dialysis + diabetes*2
Prognosis of dialysis patients with diabetes

is comparable to that for patients with heart
failure or aggressive cancers
Heart failure
Stomach cancer
Esophageal cancer
Lung cancer
Pancreatic cancer
Reprinted with permission from Elsevier
20
40
60
80
100
5-year relative survival (%)1

*5-year adjusted survival in a different study based on data from the ERA-EDTA Registry.
1. Nordio M, Limido A, Maggiore U, et al; Italian Dialysis and Transplantation Registry. Survival in patients treated by long-term dialysis compared with the
general population. Am J Kidney Dis. 2012;59(6):819-828. 2. European Renal Association-European Dialysis and Transplant Association. ERA-EDTA
Registry: Annual Report 2011. http://www.era-edta-reg.org/files/annualreports/pdf/AnnRep2011.pdf. Accessed January 9, 2014.
Decline in Estimated Glomerular Filtration Rate and Subsequent Risk of End-Stage Renal Disease and
Mortality. CKD Prognosis Consortium
ERCT
JAMA. 2014;311(24):2518-2531.
ERCT
Risk of End-Stage Renal Disease by Change in Estimated Glomerular Filtration Rate (GFR) During a 2-Year Baseline Period, First Estimated GFR, and Subsequent Follow-up.
Baseline risk is calculated for participants with 0% change in estimated GFR, estimated GFR of 50 mL/min/1.73 m2, age of 60 years, male sex, nonblack race, systolic blood
pressure of 130 mm Hg, total cholesterol level of 5 mmol/L, and without diabetes or a history of cardiovascular disease.
JAMA. 2014;311(24):2518-2531.
Mortalidad
Global
All-Cause Mortality Associated With Percentage Change in Estimated GFR During a 2-Year Baseline Period. Values trimmed at less than 70% change (0.30% and 0.050% of the
study population for estimated GFR <60 mL/min/1.73 m2 and 60 mL/min/1.73 m2, respectively) and greater than 40% change (5.8% and 0.46% of the population for estimated
GFR <60 mL/min/1.73 m2 and 60 mL/min/1.73 m2, respectively). In the top 2 panels, the diamonds indicate the reference point of 0% change in estimated GFR.
JAMA. 2014;311(24):2518-2531.
Mortalidad
Global
Risk of All-Cause Mortality by Change in Estimated Glomerular Filtration Rate (GFR) During a 2-Year Baseline Period, First Estimated GFR, and Subsequent Follow-upBaseline risk is
calculated for participants with 0% change in estimated GFR, estimated GFR of 50 mL/min/1.73 m2, age of 60 years, male sex, nonblack race, systolic blood pressure of 130 mm
Hg, total cholesterol level of 5 mmol/L, and without diabetes or a history of cardiovascular disease.
JAMA. 2014;311(24):2518-2531.
TRANSLATING CKD EPIDEMIOLOGY INTO PATIENT CARE: THE INDIVIDUAL PUBLIC RISK
PARADOX
Renal survival by CKD stage and level

of albuminuria.
Marks A et al. Nephrol. Dial. Transplant. 2012;27:iii65-iii72
PARADOX
Percentage initiating RRT by 5 years for age, gender, CKD stage and proteinuria level-specific subgroups.
*There were only 18 patients with Stage 3a CKD (4569 mL/min/1.73m2) therefore results not presented.
There were no individuals in this group.
TRR
PARADOX
Percentage of GLOMMS-I cohort alive and not on RRT by 5 years for age, gender, CKD stage and proteinuria level-
specific subgroups. *There were only 18 patients with Stage 3a CKD (4569 mL/min/1.73m2) therefore results not
presented. There were no individuals in this group.
Supervivencia
Costos Directos de la ERC
Small ESRD Population Accounts for Significant Health Expenditures

1.4% ESRD patients
7.2% spending on ESRD population
Total Medicare patient population
Total Medicare spending*
0.23% ESRD patients
United
States1
Japan1-3
Total population
0.05% ESRD patients
Total health care budget
1%-2% spending on ESRD population
United
Kingdom4
Total population
0.05% ESRD patients
Total National Health Service budget
Colombia5
*Includes inpatient and outpatient costs related to dialysis and transplantation.Renal replacement therapy only.
1. US Renal Data System. USRDS 2013 Annual Data Report. 2. CIA World Factbook website. https://www.cia.gov/library/publications/the-world-factbook. Accessed October 30, 2013.
3. Nephrol Dial Transplant. 2012;27(suppl 3):iii32iii38. 4. Peritoneal Dial Int. 2011;31(suppl 2):S58-S62. 5. Cuenta de Alto Costo. 2013
ESTIMATING FINANCIAL COST OF CHRONIC KIDNEY DISEASE TO THE NHS IN ENGLAND

Estimated annual cost of direct CKD care, RRT and non-RRT patients.
Kerr M et al. Nephrol. Dial. Transplant. 2012;27:iii73-iii80
Preventing Progression of Diabetic CKD

Reduces National Healthcare Spending
Estimated reduction in 10-year spending if rate of GFR decline decreased in all
US patients with GFR of 60 mL/min*
Billions
-20
10% decrease in rate of

GFR decline

GFR decline

GFR decline
-COP19
-40
-60
-COP39
-COP60
-80
*Mathematical model developed estimate for 10-year period from 2000-2010.
Trivedi HS, Pang MM, Campbell A, Saab P. Slowing the progression of chronic renal failure: economic benefits and patients perspectives.
Am J Kidney Dis. 2002;39(4):721-729.
Estrategias de Prevencin y Tratamiento
Necesidades Insatisfechas en ERC Diabtica

No hay esfuerzos eficaces de salud pblica para reducir la tasa de
diabetes1
Las prcticas de tamizaje necesitan ser adoptadas ms ampliamente
para la identificacin y manejo de los pacientes con ERC diabtica2
Las estrategias renoprotectoras actuales son solo parcialemente
efectivas1
Lentifican pero no previenen la progresin a TRR para muchos pacientes T

20% a40% de los pacientes con ERC progresan a resultados desfavorables a
pesar de las mejores prcticas clnicas
Es necesario tener estrategias y tratamientos adicionales para mejorar

los resultados y para atrasar o parar la progresin a TRR3
1. Braun L, Sood V, Hogue S, Lieberman B, Copley-Merriman C. High burden and unmet patient needs in chronic kidney disease. Int J
Nephrol Renovasc Dis. 2012;5:151-163. 2. KDIGO CKD Work Group. 2012 Clinical Practice Guideline for the Evaluation and
Management of Chronic Kidney Disease. Kid Int Suppl. 2013;3(1):1-150. 3. Matthews DR, Matthews PC. Banting Memorial Lecture
2010^. Type 2 diabetes as an 'infectious' disease: is this the Black Death of the 21st century? Diabet Med. 2011;28(1):2-9.
Necesidades Insatisfechas de la Creciente Carga de ERC

Diabtica
La obesidad, la diabetes y las enfermedades renales relacionadas son un
problema mdico creciente en el mundo
La progresin de la ERC est relacionada directamente con aumentos de la
morbilidad, mortalidad, carga econmica y reduccin de la calidad de vida
Hay una necesidad crtica de esfuerzos efectivos de salud pblica para prevenir
la diabetes en el mundo
El tratamiento estndar actual atrasa o previene la progresin de la nefropata
diabtica de forma inadecuada
Hay una necesidad urgente de la adopcin general de estrategias de prevencin
e intervencin eficaces en la poblacin diabtica y con ERC
Una importante estrategia de intervencin es el modelo de cuidado
estructurado de monitoreo cercano de los pacientes, educacin y manejo
farmacolgico intensivo treat-to-target de los pacientes con ERC por
diabetes1
1. Leung WYS, So W-Y, Tong PCY, et al. The renoprotective effects of structured care in a clinical trial setting in type 2 diabetic patients
with nephropathy. Nephrol Dial Transplant. 2004;19:2519-2525.
Estrategias Potenciales para Prevenir o Reducir las Tasas

de Diabetes
Estrategias poblacionales para alentar el comportamiento
saludable y prevenir la aparicin de diabetes, independiente del
riesgo
Estrategias enfocadas a reducir la progresin en poblaciones de
alto riesgo con intervencin intensiva en el estilo de vida
Ciruga baritrica para los pacientes con obesidad severa con
diabetes de inicio reciente
Backholer K, Peeters A, Herman WH, et al. Diabetes prevention and treatment strategies: are we doing enough?
Diabetes Care. 2013;36(9):2714-2719.
Incidence of type 2 diabetes after bariatric surgery: population-based matched cohort study
The Lancet Diabetes & Endocrinology 2014 2, 963-968
Lifestyle Changes Effectively Prevent Diabetes Onset
Program goals1,2:
<30% of daily energy from fat
<10% of energy from
saturated fat
15 g/1000 kcal of fiber
30 min/day of moderate
physical activity
5% weight reduction
New diabetes cases per 100 person years
Finnish Diabetes Prevention Study: Achieving 5

lifestyle goals prevented diabetes for at least 7 years1
10
Reprinted with permission from Thieme Publishers
Number of goals achieved*

*In the intervention and control group, respectively, 14% and 6% of participants achieved 4 or 5 goals; 10% and 27% of
participants did not achieve any of the predefined lifestyle goals by the 3-year examination.
1. Lindstrm J, Neumann A, Sheppard KE, et al; IMAGE Study Group. Take action to prevent diabetesthe IMAGE toolkit for the prevention of type 2 diabetes in
Europe. Horm Metab Res. 2010;42(Suppl 1):S37-S55. 2. Lindstrm J, Ilanne-Parikka P, Peltonen M, et al; Finnish Diabetes Prevention Study Group. Sustained
reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet. 2006;368(9548):1673-1679.
Diet and Exercise Has a Lasting Effect on Diabetes

Risk Reduction
In a 6-year Chinese study in patients with impaired glucose tolerance,
Dietary change led to a 31% reduced risk of developing diabetes (P<0.03); exercise led to a
46% reduced risk (P<0.0005); diet plus exercise led to a 42% reduced risk (P<0.005)1
This risk reduction lasted up to 14 years after active lifestyle intervention2

100
90
Control
80
Percentage
70
Intervention
60
50
40
30
20
6-year intervention hazard rate ratio 0.49 (95% CI 0.33-0.73)

20-year follow-up hazard rate ratio 0.57 (95% CI 0.41-0.81)
10
0
0
Number at risk
Control
Intervention
10
12
14
16
18
20
27
161
27
147
23
136
14
114
Years of follow-up
135
428
105
387
69
314
48
250
40
230
37
206
34
192
1. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: The Da Qing IGT and Diabetes
Study. Diabetes Care. 1997;20(4):537-544. 2. Li G, Zhang P, Wang J, et al. The long-term effect of lifestyle interventions to prevent diabetes in the China Da
Qing Diabetes Prevention Study: a 20-year follow-up study. Lancet. 2008;371(9626):1783-1789.
Tamizaje e Intervencin Temprana para la ERC: Una

Solucin Crtica
identification of people at earlier time points in the

trajectory of CKD, with appropriate management and earlier
referral of those who would benefit from specialist kidney
services, should lead to both economic and clinical benefits.
KDIGO 2012 Clinical Practice Guideline
KDIGO=Kidney Disease: Improving Global Outcomes.

KDIGO CKD Work Group. 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kid Int Suppl. 2013;3(1):1-150.
Addressing Treatment Gaps in Diabetic CKD

Undiagnosed
diabetic CKD
Optimize blood pressure

and glucose control1
Perform annual
albuminuria test1*
Measure serum
creatinine at least annually1
Diagnosed with diabetic

CKD but untreated or
inadequately treated
Blood pressure control2
RAAS interruption via ARB

or ACE inhibitor in patients
with albuminuria2
Diabetic CKD is
progressing despite
standard of care
What can be done

about residual risk
in treated patients?
*Patients with type 1 diabetes with disease duration 5 years; All patients with type 2 diabetes starting at diagnosis.
RAAS=renin angiotensin aldosterone system; ARB=angiotensin II receptor blocker; ACE=angiotensin-converting-enzyme.
1. American Diabetes Association. Standards of medical care in diabetes2013. Diabetes Care. 2013;36(suppl 1):S11-S66. 2. KDIGO CKD Work Group.
2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kid Int Suppl. 2013;3(1):1-150.
Current Antihypertensive/Antiproteinuric Therapies Are

Inadequate in Preventing Progression of Diabetic CKD
Benefits of delayed ESRD progression became apparent after
approximately 18 months of RAAS blockade therapy
RENAAL1
Placebo
Losartan
Placebo
Risk reduction, 28%

P=0.002
20
Irbesartan
Amlodipine
Relative risk reduction, 23%

P=0.07
30
ESRD (%)
30
ESRD (%)
IDNT2
20
10
10
Residual Risk
Residual Risk
0
12
24
36
48
Months of study
No. at risk
12
18
24
30
36
42
48
54
Months of study
No. at risk
Placebo
762
715
610
347
42
Irbesartan
579
549
523
501
418
327
234
162
78
Losartan
751
714
625
375
69
Amlodipine
565
538
510
482
408
310
221
152
58
Placebo
568
542
517
487
418
302
205
141
63
Mean follow-up time in RENAAL was 3.4 years (42 months)1
Reprinted with permission from Massachusets Medical Society
RAAS=renin-angiotensin-aldosterone system. IDNT=Irbesartan Diabetic Nephropathy Trial.

1. Brenner BM, Cooper ME, de Zeeuw D, et al; for RENAAL Study Investigators. Effects of losartan on renal and cardiovascular outcomes in patients with type 2
diabetes and nephropathy. N Engl J Med. 2001;345:861-869. 2. Lewis EJ, Hunsicker LG, Clarke WR, et al; for Collaborative Study Group. Renoprotective effect of
the angiotensin-receptor antagonist irbesartan in patients with nephropathy due to type 2 diabetes. N Engl J Med. 2001;345(12):851-860.
Multifactorial Intervention for Diabetes and CKD

(Steno-2 Trial)
Summary of Steno trial multifactorial intervention
for diabetes and CKD
Treatment Goals
SBP < 130 mm Hg
DBP < 80 mm Hg
Glycosylated hemoglobin < 6.5%
Total cholesterol < 175 mg/dL (4.53 mmol/l)
Triglycerides < 150 mg/dL (1.7 mmol/l)
ACE inhibitor or ARB irrespective of blood pressure
Aspirin irrespective of prevalent vascular disease
Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008;358(6):580-591.
Residual Mortality Risk With Intensified Multifactorial Intervention

in Patients With Type 2 Diabetes With Persistent Microalbuminuria
In the STENO 2 trial
CKD
80
60
Intensive therapy
70
Intensive therapy
50
Conventional therapy
Conventional therapy
60
No. of patients
Cumulative incidence of death (%)
Primary study endpoint*
50
40
P=0.02
30
40
30
20
20
10
10
Residual Risk
0
0
9 10 11 12 13
At 4 yr
At 8 yr
Post-trial**
At 13 yr
Years of follow-up
No. at Risk
Intensive therapy
80
Conventional therapy 80
78
80
75
77
72
69
65
63
62
51
57 39
43 30
Reprinted with permission from Massachusets Medical Society
The following targets were used for the Intensive therapy group: HbA1c <6.5%, fasting serum total cholesterol <175 mg/dL, fasting serum
triglyceride <150 mg/dL, SBP <130 mm Hg, and a DBP <80 mm Hg.
*Time to death from any cause. **Post-Trial refers to the number of patients in whom the condition progressed during the period from
the end of the original intervention trial to the endpoint examination after an average of 13.3 years of follow-up.
Gaede P, Lund-Andersen H, Parving HH, Pedersen O. Effect of a multifactorial intervention on mortality in type 2 diabetes. N Engl J Med. 2008;358(6):580-591.
Systemic Implementation Strategies to Improve Hypertension: The Kaiser Permanente Southern California
Experience
Canadian Journal of Cardiology 30 (2014) 544-552
Systemic Implementation Strategies to Improve Hypertension: The Kaiser Permanente Southern California
Experience
Canadian Journal of Cardiology 30 (2014) 544e552
El papel de especialistas en el manejo de la salud de poblaciones con enfermedades

crnicas: el ejemplo de la ERC.
Kaiser Permanente Hawaii: 240000 afiliados con 10000 pacientes con ERC (TFG < 60 o
Proteinuria 0.3 g /d)
110 mds generales remiten a 6 nefrlogos
Estratificacin del riesgo

Alto: TFG< 20 O TFG20-39 con 2 gram proteinuria O 4 gram proteinuria
Bajo: TFG 30 Y <1 gram proteinuria
Medio: Sin alto y sin bajo
Remisin con riesgo alto o con::

1. ERC sin diagnstico claro
2. ERC potencialmente inestable tal como nefritis lpica nephritis
3. Hipertensin refractaria
4. ERC con progresin rpida, con prdida de TFG 10 ml/min.
BMJ 2009;339:b2395
El papel de especialistas en el manejo de la salus de poblaciones con enfermedades

crnicas: el ejemplo de la ERC.
Menor eficaca Cualquiera con ERC
Y eficiencia
Pacientes con dao orgnico
Pacientes con mayor riesgo de progresin y de morbimortalidad
Pacientes con riesgo alto que se benefician ms con la ayuda de

un especialista que de un generalista
Pacientes con riesgo alto que se benefician ms y son ms costo
Mayor eficaca efectivo con la ayuda de un especialista que de un generalista
Y eficiencia
BMJ 2009;339:b2395
The role of specialists in managing the health of populations with chronic illness: the
example of chronic kidney disease
RESULTADOS
2004
2008
60%
56%
45%
30%
36%
32%
35%
18%
15%
12%
0%
Remisin tarda
HD inicio ambulatoio
BMJ 2009;339:b2395
N = 1263
Cumplimiento de metas del Programa

PREVEN-SER - COMFAMA
Julio 2012 - Junio de 2013
Medida/Meta
% inicial que
cumplen la meta
% ltima consulta
que cumplen la meta
P < 5 mg/dL (> 80%)
82.0%
87.5%
Que reciban Nefroprotectores (> 80%)
37.9%
82.5%
Hb > 11 g/dL (> 80%)
68.7%
82.4%
Albmina 3.8 g/dL (>80%)
68.2%
80.0%
HbA1c < 7.5% (> 80%)
71.4%
79.6%
PA 140/80 mmHg (> 80%)
55.3%
68.2%
Albuminuria < 300 mg (>75%)
54%
64.2%
PTH < 110 pg/dL (> 70%)
55.4%
62.1%
C-LDL 100 mg/dL (> 80%)
52.2%
68.3%
Deterioro de TFG > 5 mL/min/ao (<

20%)
16.9%
Alvaro Mercado MD
Programa Gestin de Riesgo ERC

DAVITA Medelln
N = 286
Pacientes Controlados en Diferentes Indicadores (%)
100
88.6
83.7
77.3
74.8
75
64.2
50
25
0
HbA1c<7.5%
PAS<140
PAD<90
LDL<110 TFG<5 ml/min/ao
Alvaro Mercado MD46
Estimated GFR reporting is associated with decreased nonsteroidal anti-inflammatory drug

prescribing and increased renal function
Kidney International (2013) 84, 174178;
El Cuidado de Enfermera Mejora los Resultados Renales en Pacientes con ERC

Multifactorial Approach and Superior Treatment Efficacy in Renal Patients with the Aid of Nurse Practitioners (MASTERPLAN)
J Am Soc Nephrol 25: 390398, 2014
Why Does Patient Activation Matter? An Examination of the Relationships

Between Patient Activation and Health-Related Outcomes
#Level 1 of patient activation (scores 047.0) indicates that an individual may not yet believe the patient role is important, level 2 (scores 47.1
55.1) indicates a patient lacks confidence and knowledge to take action, level 3 (scores 55.267.0) indicates a patient is beginning to engage in
recommended health behaviors, and level 4 (scores 67.1100) indicates a patient is proactive about health and engages in many recommended
health behaviors
J Gen Intern Med 2011. 27(5):5206
practice (increase of 2.0 ml/min per raise the question of whether the
2
1.73
m
during a follow-up period of clinical effects of the audit-based eduEducacin basada en auditora: un programa potencialmente efectivo en mejorar los logros
approximately 22.5 years). Further- cation program were worth the assode
las guas
ERC
more,
theen incidence
of cardiovascular ciated time, efforts, and costs.
Effect on clinical outcomes

Systolic blood pressure (mm Hg)
Usual practice
Target achievement (%)
Guidelines and
prompts
Renal function (ml/min per 1.73 m )
Audit-based
education
Cardiovascular event (%)

Mortality (%)
ACEi/ARB medication (%)
10
0
5
Change
10
15
Figure 1 | Overview of the effect of audit-based education on clinical outcomes.

ACEi, angiotensin-converting enzyme inhibitor; ARB, angiotensin receptor blocker.
Kidney International (2013) 84
Kidney International (2013) 84, 436438.
AVANCE EN EL SISTEMA DE SALUD EN PAGO POR RESULTADOS

COLOMBIA
El monto total recaudado ser distribuido en el primer ao de aplicacin de la presente resolucin, con base en el
periodo julio 2013 a junio 2014 con la informacin que publique la cuenta de alto costo en enero de 2015,
atendiendo los siguientes porcentajes: el 40% para ajustar la siniestralidad que enfrenta cada EPS-C, EPS-S y E0C;
y el 60% restante, entre las EPS-C, EPS-S y EOC que cumplan los indicadores o metas propuestas por el Ministerio
de Salud y Proteccin Social, con el fin de incentivar la gestin del riesgo en salud. Los indicadores o metas sern
de proceso o resultado y tendrn que centrarse en las enfermedades precursoras de la enfermedad renal
crnica. Con el fin de incentivar la gestin de riesgo en salud, los resultados en salud y evitar la seleccin adversa
por parte de las aseguradoras, los indicadores o metas se estructuran por etapas.
En una primera etapa, los indicadores o metas se centrarn en procesos y en resultados y conforme se mejore
la gestin y la informacin, se migrar exclusivamente hacia indicadores de resultados. En esta primera etapa se
establecern dos indicadores de proceso y dos de resultado y se distribuirn los recursos entre las EPS-C, EPS-S y
EOC que superen el promedio, meta o variacin establecida en cada indicador segn anexo que hace parte
integrante de esta Resolucin. Los indicadores de proceso pesarn el 70% y los indicadores de resultado el 30%.
Esta primera etapa no podr durar ms de dos aos, contados a partir del 2015, y se podrn incorporar
indicadores de resultados o modificacin a las metas de medicin en el 2016. En el Anexo de la presente
resolucin se presentan los indicadores iniciales.
En la segunda etapa se deber migrar hacia indicadores de resultados de salud y el Ministerio de Salud y
Proteccin Social establecer metas concretas para cada indicador. Los indicadores se debern concertar con el
Ministerio de Hacienda y Crdito Pblico, las EPS y las sociedades cientficas, segn corresponda. Los recursos se
distribuirn entre las EPS- C, EPS-S y EOC que superen la meta.
MINSALUD COLOMBIA. RESOLUCION 248 DE 2014

COLOMBIA
ANEXO
Primera etapa Indicadores iniciales
A. Indicadores de Proceso:
Al. Porcentaje de pacientes captados con enfermedades precursoras.
Mide: La bsqueda activa de accesibilidad de afiliados en riesgo de desarrollar Enfermedad Renal
como consecuencia de padecer la Hipertensin Arterial y la Diabetes Mellitus las cuales son
consideradas como enfermedades precursoras de la Enfermedad Renal Crnica.
Numerador: Se toma de la base entregada por la CAC los pacientes diagnosticados con las
enfermedades precursoras (HTA DM)
Denominador: Se toma la poblacin registrada en BDUA activos entre los 18 y 69 aos y las
prevalencias de cada enfermedad, la fuente de informacin fue la ENS 2007.
A.2. Porcentaje de pacientes con enfermedades precursoras, estudiados (pacientes con los
exmenes necesarios para confirmar el diagnstico) para ER.
Mide: El diagnstico temprano de la enfermedad renal crnica. Este indicador mide el porcentaje de
pacientes que una vez diagnosticados con HTA o DM, se les realiza el estudio pertinente para confirmar
o descartar compromiso renal.
Numerador: Se toma de la base entregada por la CAC los pacientes con alguna de las enfermedades
precursoras (HTA DM) a los cuales se les prctico el examen que confirma o descarta la ERC.
Denominador: Se toma de la base entregada por la CAC los pacientes diagnosticados con las
enfermedades precursoras (HTA DM).
B. Indicador de resultado
B.1. Incidencia de ENFERMEDAD RENAL CRNICA estadio 5
Mide: La tasa de incidencia de ENFERMEDAD RENAL CRNICA estadio 5 proporciona una estimacin de la
evolucin de la enfermedad renal, permitiendo a su vez estimar el grado de progresin. Se espera una disminucin
en la aparicin de nuevos casos estadio 5 en respuesta al diagnstico y manejo oportuno y adecuado.
Numerador: Se toma de la base entregada por la CAC los pacientes a los que durante el periodo inician alguna TRR
desagregados por grupos etarios y distribuidos entre las diferentes EPS-C, EPS-S o EOC.
Incidencia ajustada de ERC5
Denominador: Poblacin registrada y activa en BDUA desagregada por grupos etarios y distribuida entre las
diferentes EPS-C, EPS-S o FOC.
Numerador: Casos esperados por grupos etarios por EPS
Denominador: Poblacin total registrada y Activa en BDUA.
B.2. Variacin de la incidencia por EPS-C, EPS-S y EOC. Este indicador incentiva la reduccin de casos incidentes
de un ao a otro entre las EPS-C, EPS-S o EOC que muestren dicha condicin.
Este indicador aplicar siempre y cuando la incidencia del pas disminuya entre un ao y otro. En el evento que la
incidencia Pas aumente estos recursos se distribuirn mediante el indicador B.1.
Mide: la variacin de la tasa de incidencia de ENFERMEDAD RENAL CRNICA estadio 5 entre el ao t-1 y el ao t. Se
espera una disminucin en la aparicin de nuevos casos estadio 5 en respuesta al diagnstico y manejo oportuno y
adecuado.
Numerador: Se toma de la base entregada por la CAC los pacientes a los que durante los periodos t y t-1 inician
alguna TRR desagregados por grupos etarios y distribuidos entre las diferentes EPS-C, EPS-S o EOC.
Denominador: Poblacin registrada y Activa en BDUA desagregadapor grupos etarios y distribuida entre las
diferentes EPS-C, EPS-S o EOC medida en el ao t.
INDICADORES ERC COLOMBIA

# TIPO
INDICADOR
1 Resultado
Control de la hipertensin arterial para

poblacion no diabetica
2 Resultado
Control de la hipertensin arterial para

poblacion diabetica
3 Resultado Control de la diabetes mellitus
4 Proceso
Medicon de HbA1c
5 Resultado Control de LDL
NUMERADOR
Nmero de pacientes con ERC e hipertensin y sin
diabetes mellitus con cifras tensionales inferiores a
140/90 mmHg
Nmero de pacientes con diagnstico de ERC y diabetes
mellitus e hipertensin arterial con cifras tensionales
iguales o inferiores a 130/80 mmHg
DENOMINADOR
Nmero de pacientes con diagnstico de ERC e
hipertensin arterial sin diabetes mellitus.
Nmero de pacientes con diagnstico de ERC e
hipertensin arterial y diabetes mellitus.
Nmero de pacientes con diagnstico de ERC y diabetes Nmero total de pacientes con diagnsticos de ERC y
mellitus con HbA1c <7.5%.
diabetes mellitus.
Nmero de pacientes con diagnstico de ERC y diabetes
mellitus a quienes se les ha realizado HbA1c en los
ltimos 6 meses.
Nmero de pacientes con ERC, con hipertensin y/o
diabetes mellitus con niveles de LDL inferiores o iguales
a 100 mg /dl
Nmero total de pacientes con diagnsticos de ERC y

diabetes mellitus
Nmero total de pacientes con ERC e hipertensin y/o
diabetes mellitus.
6 Proceso
Medicin de LDL
Nmero de pacientes con hipertensin y/o diabetes

mellitus con medicin de LDL en el ltimo ao.
Nmero total de pacientes con ERC e hipertensin y/o

diabetes mellitus
7 Proceso
Medicin de albuminuria
Nmero de pacientes con ERC estadio 1, 2, 3 y 4 con

toma de albuminuria en el ltimo ao.
Nmero total de pacientes con ERC estadio 1, 2, 3 y 4.
8 Resultado Medicin de PTH
Nmero de pacientes con ERC estadio 4 con niveles de

PTH entre 70 y 110.
Nmero total de pacientes con ERC estadio 4.
9 Resultado Progresin de la enfermedad renal
pacientes con ERC estadios 1, 2, 3 y 4 con disminucin de

Nmero total de pacientes con ERC estadio 1, 2, 3 y 4.
la TFG de ms de 5ml/min/1.73m en 1 ao
EPS
Millones ($)
1. SALUD TOTAL
7919
2. COOMEVA
7341
3. SURA
6135
4. SANITAS
2062
5. FERROCARRILES
1294
6. SOS
1272
7. CAFESALUD
1231
8. CRUZ BLANCA
1055
9. COMFENALCO VALLE
992
10. COMFAMILIAR
CARTAGENA
284
11. CAPRESOCA
273
12. EPM
184
www.cuentadealtocosto.org

COLOMBIA
Colombia tiene el mejor registro de Enfermedad Renal Crnica , Hipertensin y Diabetes de Amrica Latina , segn
investigadores europeos quienes revisaron los registros de esta patologa en el mundo.
Colombia es pionero en Amrica Latina en promover la gestin de riesgo e introducir el pago por resultados en
salud.
Es uno de los pases con mayor disminucin de la incidencia de ERC terminal. (USRDS).
Disminucin del costo del tratamiento en la terapia dialtica por paciente con un ahorro de 900 mil millones de
pesos en 5 aos (US$450 millones) al sistema de salud.
Segn el comportamiento de la enfermedad renal crnica en estadio terminal presenta un crecimiento anual en
su incidencia cerca del 6%; sin embargo, en 4 aos se han evitado el ingreso a TRR aproximadamente de 5.169
casos lo cual significa un ahorro para el sistema de salud aproximadamente de 600 mil millones de pesos.
Este mecanismo de pago por resultados en ERC, HTA y DM impacta positivamente en los pacientes porque se
identificar que prestador y asegurador realiza adecuadamente los programas de control de hipertensin, diabetes
y nefroproteccin, y de esta forma se garantiza una mejor calidad de la atencin a travs del cumplimiento de guas
de manejo clnico de las patologas, lo cual se evidencia en la evaluacin por resultados.
[SP027] A GLOBAL OVERVIEW OF RENAL REGISTRIES - NEED FOR CONSISTENCY, ADDITIONAL OUTCOMES DATA AND WIDER
GEOGRAPHICAL COVERAGE. ERA-EDTA 51st Congress, Amsterdam 2014
www.cuentadealtocosto.org
Does community-wide chronic kidney disease management improve patient

outcomes?
Changes in distribution of modality at start of RRT between 2000 and
Patients starting RRT per year at HEFT displayed as the incident count
2012. Percentage starting with a catheter in 2012 is significantly lower
and the adjusted rate per million population aged >14 years.
than in 2005, P = 0.001.
incident count and the adjusted rate per million population aged >14
years. (GP, general practice, i.e. primary care; HT, hypertension;
QOF, Quality and Outcomes Framework.)
To assess the care of patients known to the nephrology

service dying with ESRD without dialysis irrespective of their
Downloaded from http://ndt.oxfordjournals.org/ at BIBLIOTEC
F I G U R E 1 : Patients starting RRT per year at HEFT displayed as the
Nephrol Dial Transplant (2014) 29: 644649
RETOS Y TENDENCIAS EN LOS SISTEMAS DE SALUD
CAMBIO
DEMOGRAFICO
DESCENTRALIZACION
DE RESPONSABILIDAD
NUEVO SISTEMA DE
INCENTIVOS
ENFERMEDADES
CRONICAS
SISTEMAS DE SALUD
TRANSPARENCIA
ENFASIS EN
PREVENCION
EXPECTATIVA
PACIENTE
CONTENCION DE
COSTOS
ENFOQUE CENTRADO
EN EL PACIENTE

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IMPACTO

Incidence rate of ESRD, per million population, by

Temporal trends in the incidence rate of ESRD, per

Data source: Special analyses, USRDS ESRD Database.

Prevalence of dialysis, per million population, by

Distribution of the percentage of prevalent dialysis patients

Kidney transplantation rate, per million population,

Data source: Special analyses, USRDS ESRD Database. Data

Percentage of incident ESRD patients with diabetes

IDF 2014: AMRICA LATINA (estimados)

Diabetic CKD: A Growing Global Disease Population

= current total population

Global Diabetes Population1-3

Projected Cases of Diabetic CKD1-4*

Reduced eGFR, Albuminuria, and Risk of Mortality in

eGFR (mL/min/1.73 m2)

Cardiovascular mortality; eGFR

Cardiovascular mortality; ACR

All-cause mortality; ACR

Reprinted from The Lancet, with permission from Elsevier

eGFR (mL/min/1.73 m2)

Reduced eGFR, Albuminuria, and Risk of Mortality in

Cardiovascular mortality; ACR studies

All-cause mortality; ACR studies

33.9 mg/mmol (300 mg/g)

3.4-33.8 mg/mmol (30-299 mg/g)

<3.4 mg/mmol (<30 mg/g)

Reprinted from The Lancet, with permission from Elsevier

Risk of Albuminuria, Elevated Creatinine, and Death in

2.0% per year

2.8% per year

2.3% per year

Elevated plasma creatinine

175 mol/L (1.98 mg/dl)

RRT=renal replacement therapy.

Prognosis for Dialysis Patients With Diabetes Is Worse Than

Prognosis of dialysis patients with diabetes

Reprinted with permission from Elsevier

5-year relative survival (%)1

Renal survival by CKD stage and level

Marks A et al. Nephrol. Dial. Transplant. 2012;27:iii65-iii72

Marks A et al. Nephrol. Dial. Transplant. 2012;27:iii65-iii72

Marks A et al. Nephrol. Dial. Transplant. 2012;27:iii65-iii72

Costos Directos de la ERC

Small ESRD Population Accounts for Significant Health Expenditures

7.2% spending on ESRD population

Total Medicare patient population

Total Medicare spending*

0.23% ESRD patients

4.1% spending on ESRD population

0.05% ESRD patients

Total health care budget

1%-2% spending on ESRD population

0.05% ESRD patients

Total National Health Service budget

4.7% spending on ESRD population

ESTIMATING FINANCIAL COST OF CHRONIC KIDNEY DISEASE TO THE NHS IN ENGLAND

Kerr M et al. Nephrol. Dial. Transplant. 2012;27:iii73-iii80

Preventing Progression of Diabetic CKD

10% decrease in rate of

20% decrease in rate of

30% decrease in rate of

Estrategias de Prevencin y Tratamiento

Necesidades Insatisfechas en ERC Diabtica