Third, low transplantation rate and low mortality rate in dialysis

patients further retains the numbers Lumacaftor solubility dmso of the dialysis patient pool.29 Diabetes mellitus (DM) (43.2%), chronic glomerulonephritis (CGN) (25.1%), hypertension (8.3%) and chronic interstitial nephritis (2.8%) are four major underlying renal diseases of ESRD in 2007. DM has become the first leading cause of ESRD by outnumbering CGN since 2000.28 Unknown causes of ESRD are especially often reported as CGN. It implies that a significant portion of patients with hypertension and chronic interstitial nephritis might be underestimated as the underlying causes of ESRD. It needs more in-depth investigation to identify the exact pattern of primary diseases of ESRD. The study based on NHI dataset showed that old age, diabetes, hypertension, hyperlipidaemia and female sex were associated with a higher risk of developing CKD.12 A prospective cohort study by Wen et al.13 further demonstrated that older age, diabetes, hypertension, smoking, obesity and regular use of herbal medicine were more common in the CKD group, and CKD is prevalent in 37.2% of the population aged over 65 years. Furthermore, hypertension, diabetes, hyperlipidaemia, smoking, obesity, low socioeconomic state and regular user of Chinese herbal drugs were significant risk factors for CKD. The association of Chinese

herbal therapy with CKD and ESRD needs to be emphasized here. Herbal therapy is independently associated with risk of CKD in adults not using analgesics.30 Intake of Chinese herbs containing aristolochic HSP phosphorylation acid has Sorafenib price been reported as the cause

of advanced renal failure in Taiwan.31–33 Chinese herbal products containing aristolochic acid, Mu-ton and Fangi have been banned by the Department of Health (DOH) in Taiwan since 2003. The beneficial effect of this action still needs to be observed. Additionally, the second wave of the TW3H Survey (unpubl. data, 2009) stated that metabolic syndrome exerted a 34% higher risk for CKD stage 3–5, which is similar to reports from the USA, Japan and Korea.20,34,35 The above well-established risk factors of CKD may not explain why the high incidence and prevalence of ESRD has developed in Taiwan. Other potential risk factors needs to be further explored. First, chronic lead intoxication may play a key role in the pathogenesis of CKD in some victims of chronic exposure without obvious clinical presentations of intoxication.36 This nephrotoxic heavy metal may accumulate and contribute to CKD silently. Reducing lead overload by administration of i.v. ethylene diamine tetra acetate has been proved to slow down the deterioration of impaired renal function.37 Second, both hepatitis B and C are endemic diseases in Taiwan with seropositive rates of 12–15% for hepatitis B surface antigen and 3–5% for anti-hepatitis C virus in general populations.