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Saudi Journal of Kidney Diseases and Transplantation
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EDITORIAL Table of Contents   
Year : 2003  |  Volume : 14  |  Issue : 4  |  Page : 456-461
Changing Profile of Causes of Chronic Renal Failure

Nephrologist, Belhoul Apollo Hospital, Dubai, United Arab Emirates

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The incidence and prevalence of end-stage renal disease (ESRD) is increasing. Diabetic nephropathy has increased in absolute numbers and as a proportion of patients with ESRD. This is almost totally accounted for by the explosive outbreak of Type 2 diabetes mellitus (DM). The world is in the midst of an epidemic of Type 2 DM and hence this trend is likely to continue for some more time. The contribution of glomerulonephritis as a proportion of patients with chronic renal failure (CRF) has declined due to increase in other causes such as diabetes. The annual incidence of IgA nephropathy, which is also a very common cause of renal insufficiency, has not changed. The incidence of focal segmental glomerulosclerosis is increasing while that of membranoproliferative glomerulonephritis is decreasing. Peak incidence of ESRD due to hypertension has shifted to a higher age-group. The proportion of renovascular disease as a cause of ESRD is also increasing. Human immunodeficiency virus associated nephropathy is the third leading cause of ESRD in African-Americans aged 20-64 years. Other diseases such as analgesic nephropathy and lead nephropathy are slowly disappearing. The significance of elevated body lead in patients with varying degrees of renal insufficiency requires further evaluation. The incidence of CRF is significantly higher in the elderly and hence there is a "graying" of CRF population. Census projections show that this trend will continue into the foreseeable future. The incidence and prevalence of ESRD vary between different populations, countries and within countries. The reason for the variations requires further study.

Keywords: Chronic renal failure, Etiology, Diabetic nephropathy, Prevalence.

How to cite this article:
Thomas PP. Changing Profile of Causes of Chronic Renal Failure. Saudi J Kidney Dis Transpl 2003;14:456-61

How to cite this URL:
Thomas PP. Changing Profile of Causes of Chronic Renal Failure. Saudi J Kidney Dis Transpl [serial online] 2003 [cited 2022 Dec 2];14:456-61. Available from: https://www.sjkdt.org/text.asp?2003/14/4/456/32909

   Introduction Top

The incidence and prevalence of end-stage renal disease (ESRD) is increasing. The incidence is forecast to increase by 4.1% per year up to 2010 in the United States (US). [1]

The proportion of various diseases causing chronic renal failure (CRF) and their absolute numbers are barometers of chronic renal diseases occurring in the community. Aware要ess of the cause of CRF helps the renal physicians to anticipate problems during renal replacement therapy and to take preventive measures for the community. Unfortunately, the cause of CRF may be unknown in many cases. The proportion of patients with CRF of uncertain etiology varies from 5.9% to 18% in the developed world [2],[3] and 16.2% to 46% in the developing world. [4],[5] In Australia, where nearly 75 % of diagnoses of glomerulo要ephritis are supported by renal biopsy, the uncertain category has come down to 7% in 2000. [2] The proportion of patients with uncertain etiology was 5.9% in the US in 1989-1992 [3] and 18% in the UK.

   Changing Profile of Glomerulonephritis Top

The incidence of glomerulonephritis has remained relatively stable, varying between 11 and 16 per million population, according to a study which analyzed data accumulated from several national renal registries of Europe consisting of 57371 patients starting renal replacement therapy between 1980 and 1999. [6] However, in relative terms, the contribution of glomerulonephritis/sclerosis declined from over 30% to less than 15% due to increase in other causes such as hypertension and diabetes. Between 1982 and 1992, the pro計ortion of patients with primary glomerulo計athy has decreased from 25% to 19% in France. [7] The Italian renal biopsy registry shows that IgA nephropathy is the commonest diagnosis made following a renal biopsy, accounting for 36.9% of renal biopsies. [8] Also, the incidence of IgA nephropathy in the Italian population was estimated to be 8.4 per million population in 1993. However, the annual incidence of IgA nephropathy over a 15-year period has not changed. [9] There is a trend of increasing incidence of focal segmental sclerosis. [10] Less common diseases such as membranoproliferative glomerulo要ephritis have decreased. [9],[11] These changes are likely to be reflected on the profile of CRF over the next few years.

Diabetic Nephropathy (DN)

Diabetic Nephropathy (DN) as a cause of ESRD has increased in absolute numbers and as a proportion of patients with CRF. Increasing incidence and prevalence of DN is almost totally accounted for by the explosive outbreak of Type 2 Diabetes Mellitus (DM). [12] Data from The Australia and New Zealand Dialysis and Transplant Registry show that DN has increased as a proportion of all new patients from 8% in 1983 to 22% in 2001. In New Zealand, DN as a cause of renal failure has increased from 26% in 1983 to 36% in 2001. [2] The number of cases of DN from Type 1 DM has remained stable while the cases of DN secondary to Type 2 DM has increased three fold between 1984 and 1994. [13] Similar increase in number and proportion of patients with DN has been reported in many other countries such as France, [7] Italy, [14] and US. [15] The world is in the midst of an epidemic of Type 2 DM and hence this trend is likely to continue for some more time. [16]

Hypertensive Nephrosclerosis

Long-standing hypertension is an important cause of CRF although it is difficult to differentiate from occult renal diseases with secondary hypertension. Peak incidence of ESRD due to hypertension which was in the age-group of 40-49 has shifted to the age茆roup of 50 to 59 years. [17] ESRD attributed to hypertension or vascular disease fell to less than half its former level between 1972 and 1991 in persons aged 15-54 years. No such fall was detected in persons aged 55 years or more. [18] In central and eastern European countries, the number of ESRD patients with the diagnosis of hypertensive nephropathy has increased which was accompanied by an increase in proportion of elderly patients. [19] These changes are possibly due to better aware要ess and treatment of hypertension which has delayed the occurrence of ESRD.

Human Immunodeficiency Virus (HIV) Associated Nephropathy

HIV-associated nephropathy occurs almost exclusively in black patients. The majority of published cases are of patients who present with acquired immunodeficiency syndrome. This disease is currently the third leading cause of ESRD in African-Americans aged 20-64 years. [20],[21] The progression of the disease may be prevented by anti-retroviral therapy. [22]

Renovascular Disease

The proportion of renovascular disease as a cause of ESRD increased from 1.4% in 1991 to 2.1% in 1997. [23] The annualized percent苔ge of growth for renovascular disease was 12.4%, which was substantially higher than all causes of ESRD. The risk of renovascular disease correlated with increasing age. Surgical or angiographic correction of renal artery stenosis does not necessarily lead to restor苔tion of renal function which suggests that other additional factors may be responsible for renal insufficiency. [23]

Analgesic Nephropathy

The term analgesic nephropathy is usually reserved for the chronic interstitial nephritis caused by prolonged high consumption of analgesics. It remains an important cause of renal failure in some European countries, Australia and South Africa [24],[25],[26] The great majority of cases are caused by consumption of mixtures of analgesics. Over a 10-year period the percentage of patients with analgesic nephropathy has decreased in many European countries and the registry data showed a reduction from 3% to 2%. Switzerland, which had the highest prevalence of analgesic nephro計athy, has experienced a decrease from 28% to 12% over the same duration. [25] Some 20 years after withdrawal of phenacetin from the market, analgesic nephropathy has almost disappeared as a cause of CRF in Sweden and Denmark, and the same may be expected to occur in countries like Switzerland and Belgium in the not too distant future. How苟ver, daily long-term use of acetaminophen alone may also be associated with renal dysfunction. Its impact on causation of CRF may become evident in future. [24],[26]

Lead Nephropathy

Since the introduction of higher industrial standards, chronic lead intoxication has virtually disappeared in Europe although a high prevalence of elevated body lead has been noted in patients with varying degrees of renal failure, partly reflecting occupational exposure before these precautions were imposed. [27],[28] A high percentage of patients with gout, hypertension and CRF have an excessive lead burden, and about 15% of the patients diagnosed as 'essential' hypertension also show high lead burden. A history of overt lead exposure was lacking in these patients. [29] The exact contribution of sub clinical lead intoxication in the causation of CRF is yet to be established.

Reflux Nephropathy

Treatment of children with vesicoureteric reflux has not been accompanied by the expe苞ted reduction in the incidence of ESRD attributable to reflux nephropathy. [30] The slight increase in incidence of ESRD due to reflux nephropathy could be attributed to changing diagnostic practices.

   Chronic Renal Failure in the Elderly Top

The incidence of CRF is significantly higher in the elderly. The incidence was 588 per million per year in those aged 80 years or above compared to 58 per million per year in those aged 20-49 years. [31] The mean age of patients with ESRD has increased from 44 years to 55 years. [32] There has been an alarming increase in the number of patients with CRF aged over 60 years. [33] Persons over 65 years accounted for 20% of total enrollment in 1978 compared to 29% of total enrollment in 1987. The proportion of French patients over 65 years registered in the EDTA-ERA Registry has increased from 14% to 24% during the same period. [7] Similarly, the number of patients aged 75 years or more having CRF has tripled from 5% to 15%. [7] With incre苔singly older patients being included for renal replacement therapy, the etiologic factors are also likely to change. In the older patients, DM and vascular diseases may account for a larger proportion of patients with CRF in contrast to the younger patients in whom glomerulonephritis is more common. Census projections show that the "graying" of the ESRD population will continue into the foreseeable future. [34]

   Chronic Renal Failure in Children Top

The proportion of children under five years with ESRD has increased from 0% to 22% between 1968 and 88 [35] in UK. Similar findings have been documented in other reports [18],[36] This change may be attributed to increasing referral for renal replacement therapy, because except for an 11% decrease of glomerulo計athies, no noticeable changes have been observed in the proportion of various primary renal disease categories in this age-group over the past 20 years. [37] Obstructive uropathies continue to be the commonest cause of CRF in children accounting for 42% of the cases. Glomerulopathies accounted for 27% and renal hypoplasia accounted for 15% of the cases.

   Variations in the Causes of Renal Failure Between Countries and Within a Country Top

There are significant differences in the incidence and prevalence of ESRD within countries. The incidence in black Americans was 424 per million population compared to 114 per million population in white Americans. [38] In Australia, the incidence of CRF in aboriginals was several fold higher than in whites. Similarly, the prevalence of Type 2 DM and DN was considerably higher among aboriginals, Maoris, and Pacific islanders. [39] A longitudinal study of 62,432 diabetic patients in California showed that the relative risk of ESRD is 2.03, 1.85, and 1.46 for blacks, Asians, and Latinos, respectively compared to whites. [40] A study from UK reveals that Asian Indians have increased age-adjusted incidence of CRF due to diabetes, glomerulonephritis and chronic pyeloneph訃itis. [41] Diabetes is more common in the USA than in Australia and Europe. Analgesic nephro計athy is a major cause of ESRD in Australia and parts of Europe. The exact incidence of renal failure in many developing countries is not clearly known, but may actually be higher than in other countries.

   References Top

1.Xue JL, Ma JZ, Louis TA, Collins AJ. Forecast of the number of patients with end貞tage renal disease in the United States to the year 2010. J Am Soc Nephrol 2001; 12(12):2753-8.  Back to cited text no. 1    
2.Disney AP. 24 th annual report of Australia and New Zealand Dialysis and Transplant Registry, 2001 report. Adelaide, South Australia.  Back to cited text no. 2    
3.US Renal Data System (1995). USRDS 1995 annual data report. The National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD.  Back to cited text no. 3    
4.Mittal S, Kher V, Gulati S, Agarwal LK, Arora P. Chronic renal failure in India. Ren Fail 1997;19(6):763-70.  Back to cited text no. 4    
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6.van Dijk PC, Jager KJ, de Charro F, et al. Renal replacement therapy in Europe: the results of a collaborative effort by the ERA胥DTA registry and six national or regional registries. Nephrol Dial Transplant 2001; 16(6):1120-9.  Back to cited text no. 6    
7.Jacobs C, Selwood NH. Renal replacement therapy for end-stage renal failure in France: current status and evolutive trends over the last decade. Am J Kidney Dis 1995;25(1):188-95.  Back to cited text no. 7    
8.Schena FP. Survey of the Italian Registry of Renal Biopsies. Frequency of the renal diseases for 7 consecutive years. The Italian Group of Renal Immunopathology. Nephrol Dial Transplant 1997;12(3):418-26.  Back to cited text no. 8    
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11.Iitaka K, Saka T, Yagisawa K, Aoki Y. Decreasing hypocomplementemia and membranoproliferative glomerulonephritis in Japan. Pediatr Nephrol 2000;14(8-9): 794-6.  Back to cited text no. 11    
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13.Rodriguez JA, Cleries M, Vela E. Diabetic patients on renal replacement therapy: analysis of Catalan registry data, Renal Registry Committee. Nephrol Dial Transplant 1997; 12:2501-9.  Back to cited text no. 13    
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19.Rutkowski B. Changing pattern of end-stage renal disease in central and eastern Europe. Nephrol Dial Transplant 2000;15(2):156-60.  Back to cited text no. 19    
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21.Ross MJ, Klotman PE, Winston JA. HIV苔ssociated nephropathy: case study and review of the literature. AIDS Patient Care STDS 2000;14(12):637-45.  Back to cited text no. 21    
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23.Fatica RA, Port FK, Young EW. Incidence trends and mortality in end-stage renal disease attributed to renovascular disease in the United States. Am J Kidney Dis 2001;37(6):1184-90.  Back to cited text no. 23    
24.Sandler DP, Smith JC, Weinberg CR, et al. Analgesic use and chronic renal disease. N Engl J Med 1989;320(19):1238-43.  Back to cited text no. 24    
25.Brunner FP, Selwood NH. End-stage renal failure due to analgesic nephropathy, its changing pattern and cardiovascular mortality. EDTA-ERA Registry Committee. Nephrol Dial Transplant 1994;9(10):1371-6.  Back to cited text no. 25    
26.Perneger TV, Whelton PK, Klag JM. Risk of kidney failure associated with the use of acetaminophen, aspirin, and nonsteroidal anti虹nflammatory drugs. N Engl J Med 1994, 331(25), 1675-9.  Back to cited text no. 26    
27.Koster J, Erhardt A, Stoeppler M, Mohl C, Ritz E. Mobilizable lead in patients with chronic renal failure. Eur J Clin Invest 1989;19(2):228-33.  Back to cited text no. 27    
28.Staessen JA, Lauwerys RR, Buchet JP, et al. Impairment of renal function with increasing blood lead concentrations in the general population. The Cadmibel Study Group. N Engl J Med 1992; 16;327(3):151-6.  Back to cited text no. 28    
29.Sanchez-Fructuoso A, Torralbo A, Arroyo M, et al. Occult lead intoxication as a cause of hypertension and renal failure. Nephrol Dial Transplant 1996; 11(9):1775-80.  Back to cited text no. 29    
30.Craig JC, Irwig LM, Knight JF, Roy LP. Does treatment of vesicoureteric reflux in childhood prevent end-stage renal disease attributable to reflux nephropathy? Pediatrics 2000;105(6):1236-41.  Back to cited text no. 30    
31.Feest TG, Mistry CD, Grimes DS, Mallick NP. Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment. BMJ 1990;301 (6757):897-900.  Back to cited text no. 31    
32.Hylander B, Lundblad H, Kjellstrand CM. Changing patient characteristics in chronic hemodialysis. Scand J Urol Nephrol 1991;25(1):59-63.  Back to cited text no. 32    
33.Molina A, Elliott W, Wilkinson R, et al. The influence of changing age and referral for end貞tage renal failure in Newcastle upon Tyne. Health Trends 1992;24(4):142-5.  Back to cited text no. 33    
34.Eggers PW. Health care policies/economics of the geriatric renal population. Am J Kidney Dis 1990;16(4):384-91.  Back to cited text no. 34    
35.Goh D, Evans JH, Houston IB, et al. The changing pattern of children's dialysis and transplantation over 20 years. Clin Nephrol 1994;42(4):227-31  Back to cited text no. 35    
36.Scharer K, Reiss U, Mehls O, et al. Changing pattern of chronic renal failure and renal replacement therapy in children and adolescents: a 20-year single centre study, Eur J Pediatr 1993;152(2):166-71.  Back to cited text no. 36    
37.Loirat C, Ehrich JH, Geerlings W, et al. Report on management of renal failure in children in Europe, XXIII, 1992. Nephrol Dial transplant 1994;9 Suppl 1:26-40.  Back to cited text no. 37  [PUBMED]  
38.Jones CA, Agodoa L , Kidney disease and hypertension in blacks: scope of the problem. Am J Kidney Dis 1993;21(4 Suppl 1):6-9.  Back to cited text no. 38    
39.Spencer JL, Silva DT, Snelling P, Hoy WE. An epidemic of renal failure among Australian Aboriginals. Med J Aust 1998; 168(11):537-41.  Back to cited text no. 39    
40.Karter AJ, Ferrara A, Liu JY, Moffet HH, Ackerson LM, Selby JV. Ethnic disparities in diabetic complications in an insured population. JAMA 2002;287(19):2519-27.  Back to cited text no. 40    
41.Lightstone L, Rees AJ, Tomson C, Walls J, Winearls CG, Feehally J. High incidence of end stage renal disease in Indo-Asians in UK. QJMed 1995;88(3):191-5.  Back to cited text no. 41    

Correspondence Address:
Paulose P Thomas
Nephrologist, Belhoul Apollo Hospital, P.B. No. 5527, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None

PMID: 17657116

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