End-stage kidney disease (AIHW)

What is end-stage kidney disease (ESKD)?

End-stage kidney disease (ESKD) is the most severe form of chronic kidney disease, also known as Stage 5 chronic kidney disease (CKD) or kidney failure.
People with ESKD generally experience a range of symptoms and abnormalities in several organ systems due to severe loss of kidney function.
Kidney replacement therapy (KRT) in the form of dialysis or a kidney transplant is required for survival when kidney function is no longer sufficient to sustain life.

What causes ESKD?

Three major causes of ESKD are diabetes, glomerulonephritis and high blood pressure (Box 1).

Box 1: Major causes of ESKD

Diabetes and diabetic nephropathy

Diabetes occurs when the body produces too little or none of the sugar regulating hormone insulin, or cannot use it properly. High blood sugar levels can damage the blood-filtering capillaries in the kidneys.

Glomerulonephritis

Glomerulonephritis involves inflammation and damage of the filtering units of the kidneys (glomeruli), affecting their ability to filter waste products and excess water from the blood. Chronic glomerulonephritis can be caused by infections, immune diseases, inflammation of the blood vessels or conditions that scar the glomeruli, however often the cause is unknown.

High blood pressure

High blood pressure (hypertension) can damage the blood vessels supplying the kidneys. The walls of these blood vessels become thick and the internal diameter narrowed, leading to reduced blood supply and decreased kidney function. Factors that contribute to high blood pressure include, age, obesity, high alcohol consumption and high dietary salt.

All new cases of ESKD

This section includes cases of ESKD receiving dialysis or a transplant, and those who die with ESKD and do not receive these treatments.

The risk of ESKD increases with age.

During the period 2003–2007:

There were an estimated 21,500 new cases of ESKD in Australia, amounting to about 21 cases per 100,000 people.
The number of new cases increased with age, with a sharp increase from 70 years (Figure 1).
Males developed ESKD at 1.5 times the rate of females.
Indigenous Australians developed ESKD at 6 times the rate of non-Indigenous Australians.
The rate of new cases increases with remoteness and socioeconomic disadvantage.
There are currently no national data available in Australia for the total prevalence of ESKD.

Figure 1: Total incidence of ESKD by age 2003-2007

Bar chart shows the incidence of ESKD increased with age, with a sharp increase from 70 years, and tended to be higher for males across all age groups.

Source: Linked ANZDATA Registry, AIHW National Mortality Database and National Death Index. Source data

Treatment rates for ESKD

It is estimated around half of those who develop ESKD are not treated with dialysis or transplant.

When kidney function is no longer sufficient to sustain life— typically at a glomerular filtration rate of around 7–8mL/min/1.73m²—kidney replacement therapy (dialysis or transplant) is required for survival. These treatments are complex, and there are many reasons why some patients may not receive kidney replacement therapy including medical reasons, accessibility of services and personal choice.

During the period 2003–2007:

For every new case of ESKD who received dialysis or a transplant, there was around one that did not.
Around 90% of those aged under 65 received dialysis or transplant.
More than 80% of the non‑KRT‑treated cases were for people aged 70 years or over (Figure 2).

Figure 2: Number of KRT-treated and non-KRT-treated cases, by age group at ESKD onset, 2003–2007

Shaded graph shows the number of non-KRT-treated cases increased with age, with more than 80% of these cases people aged 70 years or over.

Source: Linked ANZDATA Registry, AIHW National Mortality Database and National Death Index. Source data

Cases of ESKD treated with dialysis or transplant

Every day around 6 people start dialysis or transplant treatment for the first time, and this is expected to double by 2020.

According to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), during 2009:

Around 2,300 Australians started dialysis or transplant treatment for ESKD, equating to around 10 people per 100,000 population.
Males were around 1.6 times more likely than females to start treatment for ESKD.
Indigenous Australians commence treatment for ESKD at 8 times the rate of non-Indigenous Australians.
The number of people starting treatment for ESKD each year has increased. Adjusting for changes in the population, the rate of new cases of treated ESKD increased by nearly one-fifth since 2000.
The rate of new cases of people starting KRT for ESKD is projected to increase by 80% over the next decade—to 19 per 100,000 population in 2020. The increase is projected to be mainly among patients aged 70 years and over. Diabetes is expected to contribute considerably to the increase in treated ESKD.

The number of people receiving treatment for ESKD has tripled since 1991.

As at 31 December 2009, there were around 18,300 people receiving dialysis or who had a functioning kidney transplant, an increase from 6,643 in 1991.
Since 1991 the rate of treated ESKD has almost doubled, from 41 to 79 per 100,000 population.
The male rate increased by 117% while the female rate increased by 73%.
At the end of 2008, Indigenous Australians were treated for ESKD at 6 times the rate of non-Indigenous Australians.

Figure 3: The rate of treated ESKD by sex, 1991–2009

Line graph shows the rate of treated ESKD has almost doubled, from 41 per 100,000 population in 1991 to 79 per 100,000 population in 2009. Males received treatment at a higher rate than females.

Note: Age standardised to the 2001 Australian population
Source: AIHW analysis of ANZDATA registry data. Source data

At the end of 2009, 2 out of every 3 cases of treated ESKD were for people living in Major cities (12,381 people) and only 4% of cases were from Remote and Very remote areas combined. However, the rate of treated ESKD was highest in Remote and Very remote areas (151 and 140 per 100,000 population respectively).

More ESKD patients are treated with dialysis than have a functioning kidney transplant.

Kidney transplantation is considered the preferred option for KRT by patients and health-care professionals, however dialysis is the most common treatment.
Between 1991 and 2009 the number of people with ESKD with a functioning kidney transplant more than doubled—from 3,505 to 7,926 cases. However, the number of dialysis treated ESKD increased 3-fold during the same period (3,138 to 10,341 people).
From 1994 onwards the proportion of treated-ESKD patients with a functioning kidney transplant has remained at less than 50%.

Figure 4: Proportion of transplant-treated and dialysis-treated-ESKD patients, 1991 to 2009

Line graph shows, from 1991 to 2009, transplants fell from 53 to 43 per cent and dialysis rose from 47 to 57 per cent.

Source: AIHW analysis of ANZDATA Registry data. Source data

The proportion of KRT treated ESKD patients with a functioning transplant decreases with age. Around 2 out of 3 people under 29 with treated-ESKD have a functioning kidney transplant. This compares with around 1 in 4 treated-ESKD patients aged 70–74 and only 1 in 50 people aged over 85.

Figure 5: Proportion of transplant-treated and dialysis-treated ESKD patients by age, 2009

Bar chart shows dialysis increased with age, from less than 40 per cent among people aged 55 or less to nearly 100 per cent among those aged 85 or more. Transplants decreased with age, from over 60 per cent among 55 years or less to just over 0 per cent among 85 or more.

Source: AIHW analysis of ANZDATA Registry data. Source data

Hospitalisations for dialysis

Dialysis is the most common reason for hospitalisation in Australia.

In 2009–10, regular dialysis was the most common reason for hospitalisation in Australia, accounting for over 1.1 million hospitalisations. The high number of dialysis hospitalisations reflects the need for people with ESKD to receive regular dialysis—usually three times per week.

Of the hospitalisations for regular dialysis:

Males were hospitalised at 1.6 times the female rate
Hospitalisation rates increased with remoteness
Indigenous Australians were hospitalised at 11 times the non-Indigenous rate
Hospitalisation rates were higher in the Northern Territory and similar across other jurisdictions.

Figure 6: Hospitalisation rates for regular dialysis, by geographical location of residence, 2009–10

Bar chart shows hospitalisations for regular dialysis were higher for remote and very remote areas, with more females also hospitalised in these areas.

Note: Directly age-standardised to the 2001 Australian population.
Source: AIHW National Hospital Morbidity Database. Source data

Tables for figures

Table 1: total incidence of ESKD, by age, 2003–2007 (number per 100,000 population)
Age group	Males	Females
0–4	0.8	0.3
5–9	0.8	0.6
10–14	0.5	0.8
15–19	1.6	1.3
20–24	2.6	1.7
25–29	4.1	3.1
30–34	4.8	4.0
35–39	7.3	5.0
40–44	10.4	6.8
45–49	13.7	8.7
50–54	18.5	10.8
55–59	23.6	16.3
60–64	32.1	21.2
65–69	49.8	33.7
70–74	80.6	50.1
75–79	127.5	75.8
80–84	216.1	117.5
85+	447.3	318.7

Table 2: Number of KRT-treated and non-KRT-treated cases, by age group at ESKD onset, 2003–2007 (number per 100,000 population)
Age group	KRT-treated	Non-KRT-treated
0–4	32	4
5–9	46	0
10–14	44	1
15–19	101	2
20–24	151	5
25–29	247	4
30–34	324	6
35–39	451	10
40–44	640	20
45–49	781	38
50–54	925	55
55–59	1,119	105
60–64	1,134	140
65–69	1,271	315
70–74	1,427	619
75–79	1,346	1,370
80–84	716	2,379
85–90	171	2,638
90–95	22	1,923
95–100	1	683
100+	0	104

Table 3: Rate of KRT treated ESKD by sex, 1991–2009 (number per 100,000 population)
Year	Males	Females
1991	46	36
1992	48	37
1993	51	39
1994	54	41
1995	57	43
1996	60	45
1997	63	47
1998	66	48
1999	70	49
2000	72	51
2001	75	52
2002	78	54
2003	81	55
2004	84	56
2005	87	58
2006	92	60
2007	95	60
2008	97	62
2009	98	62

Table 4: Proportion of transplant-treated and dialysis-treated-ESKD patients, 2001 to 2009
Year	Dialysis	Transplant
1991	47.2	52.8
1992	47.7	52.3
1993	48.8	51.2
1994	50.2	49.8
1995	51.6	48.4
1996	52.3	47.7
1997	52.4	47.6
1998	52.9	47.1
1999	54.1	45.9
2000	54.7	45.3
2001	55.4	44.6
2002	55.6	44.4
2003	56.2	43.8
2004	55.9	44.1
2005	56.8	43.2
2006	57.4	42.6
2007	57.7	42.3
2008	57.4	42.6
2009	56.6	43.4

Table 5: Proportion of transplant-treated and dialysis-treated-ESKD patients by age, 2009
Age group	Dialysis	Transplant
0–29	33.5	66.5
30–34	35.6	64.4
35–39	36.2	63.8
40–44	38.4	61.6
45–49	41.8	58.2
50–54	47.4	52.6
55–59	49.6	50.4
60–64	54.7	45.3
65–69	63.0	37.0
70–74	75.5	24.5
75–79	86.7	13.3
80–84	96.6	3.4
85+	98.1	1.9

Hospitalisation rates (a) for regular dialysis, by geographical location of hospital, 2009–10
	Major cities	Inner regional	Outer regional	Remote	Very remote
Male	3,514	2,638	4,114	8,959	20,945
Female	4,786	3,477	4,365	7,570	17,291

(a) Hospitalisations per 100,000, directly age-standardised to the 2001 Australian population.
Note: Numbers exclude 3,089 patients for whom a remoteness classification could not be assigned due to missing data, non-Australian residency etc.
Source: AIHW National Hospital Morbidity Database.

End-stage kidney disease

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