Acute kidney injury (AKI) is seen in 5% to 18% of all people admitted to hospital.

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1 Fact sheet number 9 The National Cardiovascular Intelligence Network Cardiovascular disease key facts Kidney disease This fact sheet is one in a series which outlines some key facts about the epidemiology of cardiovascular disease (CVD) and its risk factors. The Cardiovascular Disease Outcomes Strategy stresses the need to consider CVD as a single family of diseases and conditions linked by common risk factors, and with a common and consistent approach to management. These fact sheets are aimed at commissioners of CVD services and health and social care professionals with an interest in CVD. They provide estimates of the scale of CVD in England to aid the planning and delivery of services. They have been developed by the National Cardiovascular Intelligence Network in conjunction with experts from the CVD field. Each fact sheet uses quotes or paraphrases from published sources, followed by the full reference. We have used sources which have been appraised or quality checked although when these were not available we have used other sources which have been recommended by experts within the CVD field. For details of the development of the fact sheets please see the methods and glossary document available at Key facts about kidney disease In 2013 there were 1,881,631 adults aged 18 and over on GP lists in England with diagnosed and recorded chronic kidney disease stage 3 to 5; however, it is estimated that there are approximately a further one million people with CKD stage 3 to 5 in England who are undiagnosed. Acute kidney injury (AKI) is seen in 5% to 18% of all people admitted to hospital. At the end of 2011, 44,665 adult patients were receiving renal replacement therapy in England. What is chronic kidney disease (CKD)? There is a wide spectrum of kidney disease, which can be rapid onset (acute) or longer term (chronic). CKD is closely related to CVD and the two processes often co-exist. People with CKD are at a high risk of mortality from CVD. NICE. Clinical Guideline 73: chronic kidney disease: early identification and management of chronic kidney disease in adults in primary and secondary care, 2008 [cited 2013 Nov 1]. Available from: nice.org.uk/guidance/cg73 Page 27 1 Fact sheet number 9

2 CKD describes abnormal kidney function and/or structure. It is divided into five stages which increase in severity. Stages 3 to 5 are classified as moderate to severe CKD and stage 5 may require renal replacement therapy (RRT). It is common, frequently unrecognised and often exists together with other conditions, for example, CVD and diabetes. NICE. Quality standard 5: chronic kidney disease, 2011 [cited 2013 Nov 1]. Available from: guidance.nice.org.uk/qs5 Pages 7 and 60 What is acute kidney injury (AKI)? AKI is now the commonly accepted term for acute renal failure. It is a condition where there is a rapid reduction in kidney function. AKI is normally secondary to another illness, the most common being infection/sepsis or dehydration. There are multiple risk factors for AKI including CKD and long term vascular conditions and AKI may also be responsible for long term progression in the case of CKD. NICE. Clinical Guideline 169: acute kidney injury, 2013 [cited 2013 Nov 1]. Available from: nice.org.uk/guidance/index.jsp?action=byid&o=14258 What is end stage renal disease (ESRD)? ESRD is a long term irreversible decline in how well the kidneys are working, for which RRT is needed if someone is to live. RRT can take the form of either kidney transplantation or dialysis. Dialysis can take place either in hospital or at home. NHS Kidney Care. Kidney Disease Key Facts and Figures, 2010 [cited 2013 Nov 1]. Available from: www. healthcheck.nhs.uk/document.php?o=81 Page 3 The choice of care in ESRD is complex for people who have other conditions which are also severe. For such people, alternatives to RRT such as conservative treatment may be more appropriate. A proportion of people with ESRD are managed outside the care of renal services. John R, Webb M, Young A, Stevens PE. Unreferred chronic kidney disease: a longitudinal study. Am J Kidney Dis. 2004;43: What are the risk factors for CKD? A number of common risk factors are recognised as increasing the likelihood of individuals developing atherosclerosis and therefore CKD. Fixed risk factors are non-modifiable, but are taken into account in advising people about their overall risk. These include age, gender and family history/genetic factors. Variation in levels of CKD by fixed risk factors, along with deprivation, is described below. Lifestyle/behavioural risk factors (such as smoking, physical inactivity, poor diet and obesity) reflect an individual s circumstances and choices, and can be changed for the better to reduce personal risk of developing health problems. The epidemiology of these risk factors is described in other documents within this CVD fact sheet series, available at Department of Health. Cardiovascular Disease Outcomes Strategy [cited 2013 Nov 1]. Available from: Page 11 2 Fact sheet number 9

3 Who is at risk of CKD? The estimated prevalence of CKD stages 3 to 5 varies by age and gender (based on patients with CKD amongst those tested for kidney function in the Health Survey for England). In the 16 to 24 age group the prevalence is less than 1%; this increases to more than 29% in males and 35% in females for the 75 and over age group. The prevalence of CKD is higher in women compared to men in most population based studies. The overall prevalence of CKD stages 3 to 5 in people aged 16 and over was 7% in women and 6% in men. Roth M, Roderick P, Mindell J. Health Survey for England 10: respiratory health: chapter 8: kidney disease and renal function, 2011 [cited 2013 Nov 1] Available from: PUB03023 Page 23 Prevalence of CKD stages 3 to 5, adults, England, 2009/10 Roth M, Roderick P, Mindell J. Health Survey for England 10: respiratory health: chapter 8: kidney disease and renal function, 2011 [cited 2013 Nov 1]. Available from: PUB03023 Page 23 A number of inherited conditions are associated with kidney disease. These include polycystic kidney disease. In 2011, 7.2% of people accepted onto RRT had a primary renal diagnosis of polycystic kidney disease. UK Renal Registry. The fifteenth annual report, 2012 [cited 2013 Nov 1]. Available from: renalreg.com/reports/2012.html In certain minority ethnic groups living in England (south Asian, black), the prevalence of CKD is similar to other groups, but these groups have high rates of RRT. These minority ethnic groups also have a high proportion of people with severe CKD, suggesting that the disease progresses more rapidly. Dreyer G et al and Roderick et al cited in Roth M, Roderick P, Mindell J. Health survey for England 2010: kidney disease and renal function. Leeds: Health and Social Care Information Centre, 2011 [cited 2013 Nov 1]. Available from: Page 3 3 Fact sheet number 9

4 Socially deprived people have a higher incidence and prevalence of CKD in developed countries, though the magnitude of the effect varies between countries (Drey et al, Fored et al, Shoham et al, White et al and Krop et al). In one UK study, individuals living in the most socially deprived areas had a 45% increased risk of new diagnosis of CKD compared with those living in the most affluent areas (Drey et al). CKD progresses more rapidly in socially deprived patients (Krop et al and Merkin et al). Drey et al, Fored et al, Shoham et al, White et al, Krop et al and Merkin et al cited in Roth M, Roderick P, Mindell J. Health survey for England 2010: kidney disease and renal function. Leeds: Health and Social Care Information Centre, 2011 [cited 2013 Nov 1]. Available from: PUB03023 Page 11 How common is kidney disease in England? In 2013 there are 1,881,631 adults aged 18 and over on GP lists in England with diagnosed and recorded CKD stage 3 to 5. This represents an overall proportion, not adjusted for age, of 4.3% in the 18 and over age group. This only represents the people who have been detected and registered as having CKD in primary care; the actual prevalence will be higher. It is estimated that there are approximately a further one million people with CKD stage 3 to 5 in England who are undiagnosed. The Health and Social Care Information Centre. Quality and Outcomes Framework , 2013 [cited 2013 Nov 1]. Available from: The Health Survey for England estimates that the prevalence of CKD stages 3 to 5 is 6.4% in the over 18 population, equating to 2,801,000 people in England. Roth M, Roderick P, Mindell J. Health Survey for England 10: respiratory health: chapter 8: kidney disease and renal function, 2011 [cited 2013 Nov 1] Available from: PUB03023 Page 1 The population incidence of AKI from UK data ranges from 172 per million population (pmp) per year from early data up to 486 to 630 pmp/year from more recent series depending on the definition of AKI which is used. Feest TG et al, Stevens PE et al, Metcalf W et al and Hegarty J et al cited in The Renal Association Acute Kidney Injury Guidelines, 2011 [cited 2013 Nov 1]. Available from: GuidelinesSection/AcuteKidneyInjury.aspx The NICE AKI guidance suggested that AKI is seen in 13% to 18% of all people admitted to hospital. More recently an English study (Selby et al) suggested that AKI was present in 5.4% of all hospital admissions. Some of this variability may be due to differences in the population groups studied. Kerr M, Pannu N et al, Uchino S et al cited in NICE. CG169 Acute kidney injury. Full guideline, 2013 [cited 2013 Nov 1]. Available from: Page 11 and Selby N et al. Use of Electronic Results Reporting to Diagnose and Monitor AKI in Hospitalized Patients. Clin J Am Soc Nephrol : AKI requiring RRT has been reported in 4.9% of all admissions to intensive-care units. Metnitz PGH et al cited in The Renal Association Acute Kidney Injury Guidelines, 2011 [cited 2013 Nov 1]. Available from: 4 Fact sheet number 9

5 In 2012, the acceptance rate for renal replacement therapy (RRT) in England was 109 pmp. There were 44,665 adult patients receiving RRT in England at the end of 2011, giving an England population prevalence of 843 pmp (split by modality; haemodialysis 365 pmp, peritoneal dialysis 62 pmp and transplant 415 pmp). Overall growth in the prevalent England RRT population from 2010 to 2011 was 4.5%. The Renal Association. UK renal registry report, 2012 [cited 2013 Nov 1]. Available from: renalreg.com/reports/2012.html Page 37 Is the prevalence of CKD changing over time? The number of people diagnosed with CKD has been increasing, for example 1,589,353 people aged 18 and over were recorded as having CKD in 2008 compared to 1,881,631 in This increase could be due to higher levels of diagnosis and recording of CKD in primary care, rather than growth in underlying prevalence. The Health and Social Care Information Centre. Quality and Outcomes Framework 2008/9 and 2012/ There have been few estimates of the total (diagnosed and undiagnosed) prevalence of CKD in the English population; different populations have been sampled and varying definitions used making prevalence estimates over time impossible to interpret. Does the prevalence of CKD vary across England? Across England the prevalence of diagnosed CKD varies from 2.6% in London Strategic Clinical Network to 5.0% in East Midlands Strategic Clinical Network. These figures are not adjusted for age and so variation may be due in part to the differing age structures of the areas. National Cardiovascular Intelligence Network. Kidney disease strategic clinical network profiles, Available from: How many deaths are related to kidney disease? Routine mortality statistics of death from CKD are an under-estimate of the total number of deaths as it is not routinely recorded as the underlying cause of death, rather a contributing factor. In ,260 people in England died with an underlying cause of death recorded as chronic renal failure. This number has varied over time, with no particular trend evident, the number of people varying from 1,007 in 2000 to 1,535 in Mortality from chronic renal failure: directly standardised rate, all ages, annual trend, MFP cited in The Health and Social Care Information Centre. Indicator portal [cited 2013 Nov 1]. Available from: indicators.ic.nhs.uk/webview/ People with CKD are roughly 20 times more likely to die of CVD than to progress to ESRD. The all-cause mortality rate for CKD is 30 to 60 times higher than that of the general population. NHS Employers and GP Committee of BMA. Chronic kidney disease frequently asked questions, 2011 [cited 2013 Nov 1]. Available from: Page 16 5 Fact sheet number 9

6 AKI in hospitalised patients has a poor prognosis with mortality ranging from 10% to 80% dependent upon the severity. People with uncomplicated AKI have a mortality rate of up to 10%. In contrast, people presenting with AKI and multiple organ failure experience mortality rates of over 50%. If RRT is needed mortality rises as high as 80%. Lewington A, Kanagasundaram S. Clinical practice guidelines: acute kidney injury. 5th ed. UK Renal Association, 2011 [cited 2013 Nov 1]. Available from: AcuteKidneyInjury.aspx Page 3 A recent study based in England found that the proportion of people with AKI in hospital who die is just under a quarter (23.8%). However, this again varied by the severity of the condition. Selby N et al. Use of electronic results reporting to diagnose and monitor AKI in hospitalized patients. Clin J Am Soc Nephrol. 2012; 7: In a typical population of half a million you would expect: 16,800 people aged 18 and over diagnosed with CKD 8,900 people aged 18 and over with undiagnosed CKD 820 people on renal replacement therapy, with about 60 new people requiring RRT every year National Cardiovascular Intelligence Network. Unpublished figures calculated using fact sheet sources. This fact sheet uses information from the Health and Social Care Information Centre. Copyright 2013, Re-used with the permission of the Health and Social Care Information Centre. All rights reserved. This fact sheet uses data provided by the UK Renal Registry (UKRR). The interpretation and reporting of the UKRR data are the responsibility of the NCVIN and should not be seen as an official policy or interpretation of the UKRR or the Renal Association. Crown copyright 2013 You may re-use this information (excluding logos) free of charge in any format or medium, under the terms of the Open Government Licence v2.0. To view this licence, visit OGL or psi@nationalarchives.gsi.gov.uk. Where we have identified any third party copyright information you will need to obtain permission from the copyright holders concerned. Any enquiries regarding this publication should be sent to publications@phe.gov.uk. Published December Fact sheet number 9 PHE publications gateway number: 2013_237