Time Trends in ESRD in France and Forecast to the Year 2030

Due to the increasing number of patients in France with end-stage renal disease (ESRD) requiring renal replacement therapy (RRT), the management of ESRD is a top public health priority. As of December 31, 2015, there were 82,295 patients receiving RRT: 54% of those were on dialysis and 46% were living with a functional renal transplant.  Overall, the crude prevalence was 1232 per million inhabitants.

Two registries developed and managed by the French Biomedicine Agency include and follow patients with ESRD: the French Renal Epidemiology and Information Network (REIN), created in 2001 and specific to dialysis patients, and the CRISTAL registry, specific to transplant patients. REIN includes nephrologists, epidemiologists, patients, and public health representatives and is conducted both regionally and nationally.

The Provence-Alpes-Côte d’Azur (PACA) region integrated the REIN registry in 2004. The region has a high proportion of elderly people (19% age ≥65 years vs 17% for France). There are 81 dialysis centers, including two pediatric centers and two transplant units. Anne-Claire Durand, MSc, and colleagues recently conducted  a longitudinal study to examine the time trend of RRT for ESRD in the PACA region between 2004 and 2015; the researchers also forecast the data to 2030. Study results were reported online in BMC Nephrology [doi.org/10.1186/s12882-018-0929-y].

A total of 10,055 new patients initiated RRT in the PACA region between January 1, 2004, and December 31, 2015. Of those, 97.7% (n=9822) initiated dialysis therapy and 2.3% (n=233) received a pre-emptive renal transplant. The number of new patients steadily increased by 3.4% since 2004 (rate ratio [RR], 1.034; 95% confidence interval [CI], 1.028-1.039).

Of the patients who initiated dialysis in the PACA region, the number of patients who resided outside of PACA ranged between 1.1% and 3.1%, depending on the year. Those patients lived in the two border regions (Rhône-Alpes and Languedoc-Roussillon). The proportion of pediatric patients <20 years of age ranged from 0.2% to 1.8%, depending on the year.

The number of patients with ESRD who initiated dialysis steadily increased since 2004 by an average of 3.1% per year. In 2004, 657 patients with ESRD began dialysis versus 975 in 2015 (RR, 1.031; 95% CI, 1.025-1.037; P<.001). There was a slight increase in the number of pre-emptive renal transplants during the study period (RR, 1.156; 95% CI, 1.111-1.203; P<.001).

Between 2004 and 2015, mean age at dialysis initiation increased by 1.6 years. Among patents >80 years of age, the increase was an average 6.9% (95% CI, 5.7%-8.0%; P<.001). The proportion of patients with comorbidities also increased by an average of 5.6% per year. The percentage of obese patients increased by nearly 10 points (RR, 1.23; 95% CI, 1.105-1.141; P<.001), percentage of patients with cancer by 5 points (RR, 1.085; 95% CI, 1.064-1.106; P<.001), and percentage of patients with diabetes mellitus by 3.8 points (RR, 1.056; 95% CI, 1.046-1.066; P<.001).

During the study period, the proportion of patients initiating therapy with peritoneal dialysis was low and has remained stable over the past 3 years, at ~8%. Of the patients who initiated therapy with hemodialysis, >88% began treatment in-center.

Since the start of the study period, there was an increase of 3.7% in the number of patients receiving RRT (RR, 1.037; 95% CI, 1.034-1.039; P<.001), from 4433 patients on December 31, 2004, to 6475 on December 31, 2015. During this period, ~1000 additional patients were counted in each of the two methods of RRT: 947 additional patients treated with dialysis (RR, 1.026; 95% CI, 1.024-1.09; P<.001) and 1095 additional patients living with a functional renal transplant (RR, 1.057; 95% CI, 1.053-1.061; P<.001).

The number of renal transplants performed in PACA since 2004 gradually increased by an average of 5.2% per year (RR, 1.052; 95%CI, 1.039-1.064; P<.001). The proportion of transplants from living donors also increased, from none in 2004 to 27 in 2015.

During the study period, the number of patients with ESRD treated by dialysis and living with a functional renal transplant increased linearly and continuously. According to the linear model, if those trends persist, by 2030 the PACA will have ~7371 patients on dialysis and ~3891 patients living with a functional renal transplant to be managed, representing ~3300 additional patients on dialysis than in 2015 and ~1435 additional patients living with a functional renal transplant. The PACA region will have ~600 additional patients initiating dialysis by 2030.

The researchers cited focusing on a single region in France with certain specificities such as older patients and a lower proportion of patients on peritoneal dialysis therapy compared with other regions as a limitation to the analysis.

In conclusion, the researchers said, “The originality of this study is to focus on the number of ESRD patients and not only on incidence rates, which allows us to estimate the number of dialysis places expected in the future. This study highlighted the linear increase in the number of ESRD patients in 12 years, with no prospect of stabilization. These results enable the medical community and health authorities to anticipate the supply of care in qualitative or quantitative terms as well as to be a part of a public health approach aimed at integrating more preventive measures to combat obesity and diabetes in order to expect to stabilize the number of ESRD patients in the future.”

Takeaway Points

  1. Due to the increasing number of patients with end-stage renal disease (ESRD) who require renal replacement therapy (RRT), management of those patients is a challenge and one of the main public health priorities in France.
  2. Researchers conducted a longitudinal study to examine time trends of ESRD treated with RRT (dialysis and renal transplantation) in the Provence-Alpes-Côte d’Azur region of France from 2004 to 2015 and to forecast the data to 2030.
  3. Results highlighted the increase in the number of patients with ESRD during the study period, with no prospect of stabilization.