Outcomes and economics of ESRF

The exact number of patients with end-stage renal failure (ESRF) globally is unknown because there is neither a global registry nor an official countrywide registry in themajority of nations and sovereign states.However, in a surveyof 120 countries with established dialysis programs in 2001, 1.479 million people were estimated to have ESRF (1). Since then, an expanded follow-up survey revealed that ESRF affected 1.681 million people globally by year-end 2003 (2). Of these, only 382,000 (22.7%) received a renal transplant (RTX) and even fewer at 141,000 (8.4%) were on peritoneal dialysis (PD). The majority of patients numbering over 1.158 million (68.9%) received various forms of hemodialysis (HD) treatments to stay alive. These numbers are expected to rise in the near future due to the increasing prevalence of diabetes worldwide and increasing life expectancy. Currently, patients are distributed among 122 countries that reported having programs caring for ESRF patients. These 122 countries have a combined population of 5.8 billion, representing 92.4%of the world’s estimated 6.3 billion people at year-end 2003. Although it is tempting to define geographic regions or delineate economic systems and structures as well as to compare outcomes between them, the absence of uniformdefinitions of processes, systems and outcomes as well as standardized data collection instruments for complete tracking of diagnoses and treatments among these 122 countries preclude direct comparisons. Furthermore, the inability to quantify the impact of local culture and hereditary/genetic/environmental effects on the illness, access to care, population lifespan, patient preferences, available therapeutic strategies, and the outcomes themselves confound the interpretation of any comparison. This chapter will attempt to elucidate key factors confounding clinical outcomes, describe the economics within ESRF management, and review some available “controlled” comparison of clinical outcomes, realizing that the available data are limited mostly to the United States of America (USA), Japan, and the European Union (EU). In addition, since the majority of ESRF patients are provided renal replacement therapy (RRT) viaHD, most of the concepts in this chapter are developedwith information based on this modality.