Costs and benefits of improving renal failure treatment--where do we go?

Less than 50 years ago, a therapeutic revolution totally changed the inevitable lethal prognosis of established chronic kidney disease (CKD), as maintenance dialysis methods and renal transplantation (TX) proved the possibility of prolonged survival for patients with endstage renal failure (ESRF). The first priority of clinical nephrologists in developed countries has, therefore, been the struggle for the widest possible implementation of dialysis and transplant facilities, and the training of medical, nursing and technical staff in these new areas of medical practice. By the end of 2004, close to 1.8 million patients were treated worldwide with renal replacement therapy (RRT), 77% on maintenance dialysis and 23% living with a functional transplant [1]. To date, about 90% of patients benefiting from RRT live in the more developed countries of the Western hemisphere, Japan and Australia, while sadly, more than 5.2 billion people, 82% of the of the total world population, still have no, or only severely rationed, access to these expensive life-saving technologies [1,2]. In recent years, the skyrocketing costs of CKD/endstage renal disease (ESRD) management in developed countries due to the relentlessly increasing number of incident and prevalent patients requiring RRT has strongly stimulated the clinical applications of the ‘nephroprotection concept’ aimed at the early detection and subsequent prevention of progression of CKD, mainly through lifestyle adjustment and the use of new pharmacological agents [3]. Following this line of thought, the objective assigned to nephroprotection is, from the earliest stage of diagnosed CKD, to retard (or even avoid) progression to ESRF, while providing the patients with the longest survival, lowest morbidity, best social rehabilitation and optimal quality of life, at the lowest cost for health care public or private fund-providers. Meeting this ‘global challenge’ [4] has to take into account the quite frightful forecast of the CKD/ESRF economics, based on the current and future increase of prevalent and incident CKD/ESRD patients. These trends are mainly due to ageing of the general populations in developed countries, which increases the frequency of arterial hypertension and other vascular complications, amongst which renal atherosclerosis, together with the epidemic of type 2 diabetes mellitus [1,2,5–7]. According to the current demographic projections, by the year 2030, there will be about 360 million diabetics worldwide, among whom one in three people might (will? ) develop CKD. It is clear that no country and no health care system will be able to offer adequate RRT, and that early detection and prevention are the only means of escape from a scenario of inadequate and unequal distribution of life-saving measures such as RRT [8]. International scientific organizations have thus recently called for action to promote early detection of CKD, primarily in populations at risk (patients with diabetes or hypertension, or those with a history of family renal disease) and implementing on the widest possible scale the currently established prevention strategies aimed at slowing down the progression of CKD; these strategies are listed in Table 1 [9]. All these features play a positive role in the prevention of aggravation of CKD. Modifications of lifestyle, required especially for populations living in Western-style societies, are not limited by financial constraints, but by even more powerful barriers, of a socio-psychological nature. [10]. In fact, control of blood pressure (BP) is the cornerstone of any prevention strategy for reducing cardiovascular and renal morbidity/mortality. A review of nine meta-analyses conducted between 1992 and 2003, among which two included non-diabetic patients [11,12], four included diabetics [13–16] and three included mixed populations [17–19], yielded following conclusions [20]: (i) protective treatment includes angiotensin-converting enzyme inhibitors (ACE-Inhs) or angiotensin receptor Correspondence and offprint requests to: Dr C. Jacobs, Service de Nephrologie, Hopital de la Pitie, 83, Boulevard de l’Hopital 75013, Paris, France. Email: claude.jacobs@psl.aphp. fr; claude.jacobs@psl.ap-hop-paris.fr Nephrol Dial Transplant (2006) 21: 2049–2052