1. Dialysis in Russia, key issues Prevalence of 2HPT in Russian dialysis population Dr. Valeriy Shilo Mоscow, Russia Russian Zemplar® Advisory Board Meeting Moscow 2009

2. General information about Russia and Healthcare Dialysis in Russia Prevalence and current management of HPT in Russian Dialysis Population Zemplar

3. Macroeconomic snapshot of Russia Area - 17 075 400 sq.km. Population – 144 168 000

4. Russia: economic state Per capita GDP in international dollars, 2004 GDP = gross domestic product 52 Russia15,922 IMF 2008Russia 2008 43500 2007 14100 World Bank 2007 42 Russia14,743 World Bank 2007Russia

5. Healthcare structure/personnel 2007 5 285 Hospitals5 285 Hospitals 2 350 Policlinics2 350 Policlinics 1 152 Dispansers1 152 Dispansers 616 400 MDs 43,3 per 10 000616 400 MDs 43,3 per 10 000 1 343 300 Nurses 94,3 per 10 0001 343 300 Nurses 94,3 per 10 000 MD : nurse ratio 1:2,2MD : nurse ratio 1:2,2 12, 4 Hospital beds per 1000

7. GDP 2,6% 3,7% 3,5%

12. Data from Russian Registry of Renal Replacement Therapy Dialysis in Russia: key issues Data from Russian Registry of Renal Replacement Therapy

13. HD units distribution (number per на 100k km 2 ) by the end 2005

14. RRT centers (1998-2006) Число отделений 208 202 19 307 275 68 46 (Δ 47%) (Δ 36%) ( Δ 258%)

15. Dialysis Units (Types) Type Proportion (%) Patients # (%) Federal Academic Institution <5 5 Private Academic Institution 0 0 Federal Hospitals 1 0,1 Municipal Hospitals 85 70 Other public (Military, Railway ets) 5 <5 Private hospitals 0 0 Private ambulatoric 5 20 dialysis clinics

16. Prevalence of patients on RRT in Russia in 1998-2006 yrs (increase 13,6% ) Число больных ГД ПД Tx 8228 8817 9635 10999 11814 13097 14509 16483 17738 71,7% 6,8% 21.5% 19483

17. Access to RRT in Moscow(2006 г), whole Russia (2006 г.) in comparison to other countries (2005 г.) (International comparison. USRDS 2006) Обеспеченность на млн. населения

18. Comparison in RRT prevalence in Federal Parts of Russia 1998-2006 319 238 138 129 109 99 106 91 81,5 2006

19. Incidence rates in 2000-2006 yrs HD PD Per million pop. 2,1 15,6 16,9 19,2 20,2 24,3 29,03 1764 2458 2786 2271 2917 3485 4144 2000010203040506 Summary grouth 135%

20. Incidence rates HD + PD per Million Population in 1995-2007 Moscow, whole Russia, Austria, USA Число больных, впервые приятых на лечение ГД и ПД за год, на млн. населеня 132,3 361 26,7 39,545 5150,3 60 54

21. Age of RRT Pts (2000-2005) PrevalentIncident Children on RRT 451 pts (18,8 PMCP )

22. Prevalence of HPT an other disturbances in mineral metabolism in Russian dialysis population

23. Исследование распространенности ВГПТ в РФ фаза I – II 2008 2HPT Russian Study Vaves I-II 2008 22 центра РФ –10 Москва –3 Санкт – Петербург –Екатеринбург –Краснодар –Нижний Новгород –Петрозаводск –Самара –Липецк –Новосибирск –Кемерово –Волгоград Всего включено 1569 пациентов на ГД

24. PTH Comparison

25. PTH Distribution

26. Phosphate distribution

27. Фосфор сыворотки – сравнение с международными данными

28. Total 6 343 pts Russia 1 588 pts 2009 Q1

29. Corrected Ca distribution

30. Corrected Ca comparison

31. Са х РО4 Product

32. Available options for HPT Management in Russia Active Vitamin D sterols –Calcitriol –Alfacalcidol –Paricalcitol - not reimbursed Calcimimetics –Mimpara - not reimbursed Phosphate binders (cont)

33. Available phosphate binders in Russia Calcium carbonate Aluminum gel salts Sevelamer HCl (Renagel) – not reimbursed Calcium acetate Lantanum carbonate Not Available

34. Vit D Usage

35. Conclusion (I) RTT in Russia is still unacceptable poor comparable to industrial countries, though some improvement are obviousRTT in Russia is still unacceptable poor comparable to industrial countries, though some improvement are obvious No central (Federal) reimbursement for HD and PD creates unequal access to dialysis throughout the countryNo central (Federal) reimbursement for HD and PD creates unequal access to dialysis throughout the country From 2005 EPO and iron become available due to federal reimbursement programFrom 2005 EPO and iron become available due to federal reimbursement program Rapidly grown economy promise further improvement in health care systemRapidly grown economy promise further improvement in health care system