QJM vol. 98 no. 1 © Association of Physicians 2005; all rights reserved.
Trends in adult renal replacement therapy in the UK: 1982–2002
From the Renal Association UK Renal Registry and the Richard Bright Renal Unit, Southmead Hospital, Bristol, UK
Received 15 June 2004 and in revised form 4 October 2004
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Summary |
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Background: Following the introduction of dialysis and transplantation for the treatment of established renal failure (ERF) 40 years ago, the UK failed to match the achievements of many other countries.
Aim: To review progress with treatment for ERF in the UK in the past 20 years.
Design: Review of four cross-sectional national studies, and 1997–2002 annual UK Renal Registry data.
Methods: Data on UK patients on renal replacement treatment (RRT) were collated from three sources: European Registry reports for 1982–1990, surveys carried out within the UK in 1993, 1996, 1998 and 2002, and the UK Renal Registry database (1997–2002). Trends in acceptance and prevalence rates, median age, cause of ERF, and treatment modality were analysed and compared with current data from other countries.
Results: The UK annual acceptance rate for RRT increased from 20 per million population (pmp) in 1982 to 101 pmp in 2002. This growth was largely in those aged over 65 years, and in those with co-morbidity. Annual acceptance rates for ERF due to diabetes rose from 1.6 to 18 pmp. The prevalence of RRT increased from 157 pmp in 1982 to 626 pmp in 2002. Hospital haemodialysis has become the main modality, and is increasingly being provided in satellite units. Although rising, UK acceptance and prevalence rates are still lower than in many developed countries.
Discussion: Despite significant expansion in RRT services for adults in the UK over the last 20 years, there is evidence of unmet need, and need is expected to rise, due to demographic changes and trends in type 2 diabetes. Continuing growth in the already substantial investment in RRT will be needed, unless efforts to prevent the occurrence of ERF are successful.
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Introduction |
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Following the introduction of haemodialysis (HD) and renal transplantation in the 1960s, and of peritoneal dialysis (PD) in the early 1980s, the number of patients on renal replacement therapy (RRT) has increased progressively throughout developed countries. However, the UK has failed to match this growth. By 1982, only 157 patients per million population (pmp) were on RRT, with a new patient acceptance rate of 20 pmp, the smallest number in Western Europe. Corresponding figures from France, West Germany and Italy were nearly twice those in the UK.1 There were only 55 centres providing treatment in the UK, compared with 179 in France and 214 in Germany. This was a reflection of limited investment by the NHS in a complex, expensive, and lifelong treatment.
To what extent have things improved? This paper reviews the development of RRT in the UK over the last two decades. It describes trends in acceptance and prevalence rates, patient characteristics and treatment modalities, and compares them with other developed countries. It is timely in the light of the recently published National Service Framework for Renal Services in England.
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Methods |
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For the period 1982–1990, data were taken from the European Dialysis and Transplant Association Registry Reports,1 and for 1997 to 2002, from the Renal Association UK Renal Registry database. In addition, from 1991 to 2002, various authors participated in four national surveys of renal services commissioned by the Department of Health.2–5 The first national survey covered renal units in England only (acceptance rates 1991/2/3, prevalence rates 1993), the second England and Wales (both rates for 1996), and the third and fourth the whole of the UK with 100% response (both rates 1998, 2002). All sought information on new patients accepted for RRT (age, ethnicity, percentage with diabetic ERF), prevalent patient numbers at year-end, type of treatment, i.e. PD, HD (main renal unit, satellite unit or home) or transplant, as well as some aspects of the units’ facilities. All units returned data, except for one in the second survey.
By 2002, 37 of the 52 renal units in England and all five units in Wales had submitted data to the UK Renal Registry. All renal units in Scotland contributed a smaller dataset to the UK Renal Registry through the Scottish Renal Registry. Summary data were available for Northern Ireland for 2002. In England and Wales, the age distribution of the catchment population estimated to be covered by the units participating in the Registry was similar to that of the countries as a whole, according to data from the Office for National Statistics (ONS), enabling extrapolation of Registry data to give national rates. The ONS mid-year population estimates for England and Wales, and corresponding data from the Registrar General for Scotland, were used to calculate the population denominators for the acceptance and prevalence rates per million population.
New patients were defined as those who needed RRT for at least 90 days without recovery of renal function, and those who died within 90 days but whose renal condition was considered irreversible by the nephrologist responsible for them (the definition used by the UK Renal Registry).
Satellite units provide a chronic maintenance HD service available near to patients’ homes, largely run by nurses, and are usually sited at some distance from the parent renal centre where acute facilities are based. They do not have daily attendance by on-site medical staff. They are very heterogeneous in terms of staffing, site, size and funding structure. Temporary dialysis stations are those created in wards and other areas, pending provision of permanent facilities, to meet crises when insufficient stations are available to provide a service for the existing patients. They are mostly in main renal centres.
The data for international comparisons were collated from national Registry reports: USRDS,6 Australia/New Zealand,7 Norway,8 Netherlands,9 Canada,10 and Germany.11
Data were analysed using Excel and SAS. A general linear model analysis for data that had a Poisson distribution was used to determine whether variations in these rates were statistically significant. The SAS software package tests the data distribution and provides a correction for over dispersion of data. The 95%CIs applied to the incidence rates indicate the likely statistical variability around the annual small incident ‘sample’ of patients taken from the larger general population.
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Results |
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New patients
The number of adult patients accepted annually for RRT in the UK increased steadily from 20 pmp in 1982 to 101 pmp in 2002 (95%CI 99–104) (Figure 1). Acceptance rates in 2002 varied significantly (p < 0.0001) from 98 pmp (95%CI 95–101) in England, to 109 pmp (95%CI 93–125) in Northern Ireland, 118 pmp (95%CI 106–131) in Wales, and 120 pmp (95% CI 111–130) in Scotland.
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Most of the growth in acceptance rates was the result of changes in the referral and acceptance of older people with ERF, and to a lesser extent of diabetics (Figure 2). The median age for new patients increased from 61 in 1995 to 65.5 in 2002, and the proportion over 75 rose from 13% to 23%. In England and Wales, diabetic renal disease increased from 1.6 pmp (8% of accepted cases) in 1982 to 18 pmp (18%) in 2002, the commonest identifiable cause of ERF (Table 1). In the elderly, renovascular disease was common (11.2% in over-65s vs. 2.8% in under-65s). The ‘uncertain’ diagnosis group was large in all ages, particularly the elderly. In all age groups, just over 60% of all patients accepted for RRT were male.
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Prevalent adult patients
The UK prevalence rate increased from 157 in 1982 to 526 in 1998 (national survey), and to 626 pmp in 2002 (national survey). There was significant variation in prevalence rates between England (615 pmp), Northern Ireland (657 pmp), Scotland (684 pmp), and Wales (692 pmp) (p < 0.0001). The growth rate of prevalent patients on RRT over the last 10 years averaged 4–6% per annum.
In England and Wales, the median age for all patients on RRT in 2002 was 55.9 years, with 34% aged 65 or over, and 11% over 75 years, and has showed little change since 1997. The largest growth was in hospital HD, both in proportional and absolute terms (Figure 3). Although the number with a functioning transplant continued to rise, there was a proportional fall in this modality. The proportion of patients on home haemodialysis fell steadily from 27% in 1982 to 1.2% in 2002. There were significant age differences in treatment modalities, the youngest patients being those with functioning transplants, followed by PD and then HD (median ages 49.6, 58.3 and 64.5 years, respectively). Whilst the median age for those on HD is increasing, that for PD is decreasing.
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Supply of services
The number of main renal units has changed little over the last two decades. There has been considerable expansion of HD facilities by increasing the number of dialysis stations and the number of treatments carried out at each station during the day, but the major increase was in the number of satellite units, which has nearly trebled in England since 1993 from 36 to 101 (Tables 2 and 3). In the UK, 45% of haemodialysis stations are provided in satellite units: since 1993 the proportion in England has risen from 20% to 49%.
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Of the permanent haemodialysis stations in the UK, 47% were in satellite units at the end of 2002. The number of patients dialysing in satellite units in England rose from 476 patients in 1993 to 5703 patients in 2002, with 39.5% of all UK haemodialysis patients dialysing in such units. The scale of satellite unit usage varied between countries within the UK (Table 2).
International comparisons (Table 4)
UK acceptance and prevalence rates are lower than in many other Western countries.5–11 Annual acceptance rates are >100 pmp in many European countries, although most northern European countries, except Germany, have comparable rates to the UK. The USA in 2001 had a higher incidence at 334 pmp. The UK relies more heavily on PD (27% of dialysis patients) than most other countries except New Zealand (48% of dialysis patients) and the Netherlands (30% of dialysis patients), although the Scandinavian countries also had rates over 20%. Annual adult transplantation rates (30 pmp) and diabetic renal disease acceptance rates (18 pmp) are low.
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Discussion |
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There has been a major increase in the number of patients accepted for RRT in the UK, largely due to rising acceptance rates in the elderly, and to a lesser extent in patients with comorbidity, as indicated by the rising acceptance of patients with diabetes. There has been a lowering of the threshold for referral of older patients and of those with more co-morbidity, as well as greater acceptance by nephrologists.12,13 Similar trends in other European countries have been recorded recently.14 The annual acceptance rate for England, which is lower than for the other three UK countries, has been progressively rising (Figure 1). The annual acceptance rates for Scotland, Wales, and Northern Ireland appear to have reached a plateau since 1998, but as the populations are small in these countries, the numbers accepted are small, and these data must be interpreted with caution.
Despite the fact that diabetes was one of the most common causes of renal failure in new patients in the UK, the rate of 18 pmp (18% of all acceptances) is much lower than that observed in the US (148 pmp, 44%) or Germany (63 pmp, 36%) and in many other European countries.6,11,14 Possible explanations for the lower UK rate for diabetics on RRT include lower prevalence, under-referral of patients, better management of diabetes, and a higher death rate from cardiovascular disease before reaching RRT.
The acceptance rate required to meet the true need for RRT in the UK is unknown: the relatively low number of diabetics has been highlighted, and comparison with international data on age-specific acceptance rates for RRT suggests there may still be unmet need in the elderly. While Europe appears different from the USA (Table 4), the incidence in many European countries, whilst appearing to be reaching a plateau, is already higher than that in the UK (Table 4).
The need for RRT is also likely to increase. The incidence of ERF rises steeply with age.15 As the ethnic minorities have a low median age and an incidence of renal disease about four times that of White patients, as these populations age, there will be a substantial increase in numbers needing RRT.16,17 At the same time, the prevalence of Type 2 diabetes is expected to continue to increase.
The increase in prevalence of RRT in the past 20 years has been due to a combination of increasing acceptance rates and better survival on RRT. Improved short-term survival on RRT has been observed in the US, Europe and UK.5,18,19
In addition to the prevalence rate, the patterns of modalities used by patients on RRT are the main drivers to resource need and costs. In the UK, there has been a major increase in hospital-based HD, the most expensive form of RRT, over the last decade. PD and transplantation proportions are falling, partly because of the increasing numbers of elderly and more co-morbid patients who are unsuitable for these treatments. Consequently, to cope with the increase in HD patient numbers, and to make treatment more accessible, satellite units have developed, and main units have increased their capacity and number of haemodialysis shifts. The large number of temporary stations present within units implies that need still outstrips provision.
After the initial rapid rise in patients on PD in the UK in the 1980s, the numbers have not increased since 1995. The proportion of RRT patients in the UK on PD, although slowly falling, at 15% is still much higher than most other developed countries except New Zealand (where there are constraints on haemodialysis due to lack of resources), and the Netherlands, Sweden and Norway.
Transplantation is the least expensive form of RRT. The proportion of patients with a functioning renal transplant is the result of the balance between the rate of transplantation, and the rate of acceptance of new patients and graft failure. Cadaver organ donor rates in the UK fell from 1998–2001,20 and although there was an increase in live donors, the overall renal transplant rate declined. However more recent reports from UK transplant show that this trend has reversed.21 Nevertheless, the proportion of RRT patients with a functioning renal transplant in the UK has fallen to 46%, compared with 53% in 1993.
A programme as costly as RRT needs monitoring to improve the equity, quality, and efficiency of the care. The Renal Association UK Renal Registry, which now covers about 89% of the UK population, provides comparative audit against national standards. UK Renal Registry data continue to show inequity in provision of RRT within the UK.5
In summary, despite substantial growth of RRT in the UK in the last two decades, population need has not been met, especially in England. Simulation modelling estimates that the steady state (at which cases accepted equal those dying) will not be reached for at least 20 years.22 It is unlikely that the transplant programme will cope with this demand, as an increasing proportion of the ageing ERF population is unfit for such surgery. Thus, the major growth area will continue to be in HD, the most expensive form of RRT, highlighting the need for continuing financial investment in renal services and greater efforts to prevent ERF.
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Acknowledgments |
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We would like to thank the patients and staff of renal units for contributing data via the UK Renal Surveys and Renal Registries, and the Department of Health in England for their support and for funding and commissioning the four national reviews.
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Footnotes |
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Address correspondence to Professor T.G. Feest, Richard Bright Renal Unit, Southmead Hospital, Southmead Road, Bristol BS10 5NB e-mail: terry.feest{at}nbt.nhs.uk
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References |
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1. Wing AJ, Broyer M, Brunner FP, Brynger H, Challah S, Donckerwolcke RA, Gretz N, Jacobs C, Kramer P, Selwood NH. Combined report on regular dialysis and transplantation in Europe, X111, 1982. Proc EDTA 1983; 20:5–67.
2. NHS Executive. Renal Purchasing Guidelines. London, 1996.
3. Roderick PJ, Ferris G, Feest TG. The provision of renal replacement therapy for adults in England and Wales: recent trends and future directions. Q J Med 1998; 91:581–7.
4. UK Renal Registry Report 2000, Chapter 3. Bristol, UK Renal Registry.
5. UK Renal Registry Report 2003. Bristol, UK Renal Registry.
6. US Renal Data System. USRDS 2002 Annual Data Report: Atlas of End Stage Renal Disease in the United States. Bethesda MD, National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases, 2003.
7. ANZDATA Registry Report 2003. Adelaide, Australia and New Zealand Dialysis and Transplant Registry.
8. Norwegian Renal Registry Report 2002. Oslo.
9. ERA-EDTA Registry Annual Report 2002. Academic Medical Centre, Amsterdam, European Renal Association.
10. 2001 Report, Volume 1: Dialysis and Renal Transplantation, Canadian Organ Replacement Register. Ottawa, Ontario, Canadian Institute for Health Information, 2001.
11. Quasi-Niere. Annual data report on dialysis and transplantation in Germany for 2001/2002. Quasi-Niere, Berlin 2004. [www.quasi-niere.de]
12. Parry RG, Crowe A, Stevens JM, Mason JC, Roderick P. Referral of elderly patients with severe renal failure: questionnaire survey of physicians. Br Med J 1996; 313:466.
13. McKenzie JK, Moss AH, Feest TG, Stocking CB, Siegler M. Dialysis decision making in Canada, the United Kingdom, and the United States. Am J Kidney Dis 1998; 31:12–18.[ISI][Medline]
14. Stengel B, Billon S, van Dijk PCW, Jager KJ, Dekker FW, Simpson K, Briggs JD. Trends in the incidence of renal replacement therapy for end-stage renal disease in Europe, 1990–1999. Nephrol Dial Transplant 2003; 18:1824–33.
15. Feest TG, Mistry CD, Grimes DS, Mallick NP. Incidence of advanced chronic renal failure and the need for end stage renal replacement treatment. Br Med J 1990; 301:897–900.[ISI][Medline]
16. Soni Raleigh V. Diabetes and hypertension in Britain's ethnic minorities: implications for the future of renal services. Br Med J 1997; 314:209–13.
17. Roderick PJ, Raleigh VS, Hallam L, Mallick NP. The need and demand for renal replacement therapy in ethnic minorities in England. J Epidemiol. Community Health 1996; 50:334–9.[Abstract]
18. United States Renal Data System. Excerpts from the USRDS 2001 Annual data report: atlas of end-stage renal disease in the US. Am J Kidney Dis 2001; 38 (Suppl. 3):5–8.
19. van Dijk PCW, Jager KJ, de Charro F, Collart F, Cornet R, Dekker FW, Grönhagen-Riska C, Kramar R, Leivestad T, Simpson K, Briggs JD. Renal replacement therapy in Europe: the results of a collaborative effort by the ERA-EDTA registry and six national or regional registries. Nephrol Dial Transplant 2001; 16:1120–9.
20. UK Transplant Activity 2001. ISSN 1477-8505.
21. UK Transplant Website, 2004. [www.uktransplant.org.uk]
22. Davies R, Roderick PJ. Predicting the future demand for renal replacement therapy in England using simulation modelling. Nephrol Dial Transplant 1997; 12:2512–16.
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