Burden, Access, and Disparities in Kidney Disease

Kidney disease is a global public health problem that affects more than 750 million persons worldwide. 1GBD 2015 DALYs and HALE CollaboratorsGlobal, regional, and national disability-adjusted life-years (DALYs) for 315 diseases and injuries and healthy life expectancy (HALE), 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016; 388: 1603-1658Abstract Full Text Full Text PDF PubMed Scopus (1424) Google Scholar The burden of kidney disease varies substantially across the world, as does its detection and treatment. Although the magnitude and impact of kidney disease is better defined in developed countries, emerging evidence suggests that developing countries have a similar or even greater kidney disease burden. 2Hill N. R. Fatoba S. T. Oke J. L. et al. Global prevalence of chronic kidney disease–a systematic review and meta-analysis. PLoS One. 2016; 11: e0158765Crossref PubMed Scopus (1775) Google Scholar In many settings, rates of kidney disease and the provision of its care are defined by socioeconomic, cultural, and political factors, leading to significant disparities in disease burden, even in developed countries. 3Crews D. C. Liu Y. Boulware L. E. Disparities in the burden, outcomes, and care of chronic kidney disease. Curr Opin Nephrol Hypertens. 2014; 23: 298-305Crossref PubMed Scopus (75) Google Scholar These disparities exist across the spectrum of kidney disease—from preventive efforts to curb development of acute kidney injury (AKI) or chronic kidney disease (CKD), to screening for kidney disease among persons at high risk, to access to subspecialty care and treatment of kidney failure with renal replacement therapy (RRT). World Kidney Day 2019 offers an opportunity to raise awareness of kidney disease and highlight disparities in its burden and current state of global capacity for prevention and management. In this editorial, we highlight these disparities and emphasize the role of public policies and organizational structures in addressing them. We outline opportunities to improve our understanding of disparities in kidney disease, the best ways for them to be addressed, and how to streamline efforts toward achieving kidney health equity across the globe. Availability of data reflecting the full burden of kidney disease varies substantially because of limited or inconsistent data collection and surveillance practices worldwide (Table 1). 4Bello A. K. Levin A. Tonelli M. et al. Global Kidney Health Atlas: a report by the International Society of Nephrology on the current state of organization and structures for kidney care across the globe. https: //www. theisn. org/images/ISNₐdvocacy/GKHAtlasLinkedCompressed1. pdfGoogle Scholar Whereas several countries have national data collection systems, particularly for end-stage renal disease (ESRD) (e. g. , United States Renal Data System, Latin American Dialysis and Renal Transplant Registry, and Australia and New Zealand Dialysis and Transplant Registry), high-quality data regarding nondialysis CKD is limited, and often the quality of ESRD data is quite variable across settings. This situation is of particular concern in low-income countries. For example, a meta-analysis of 90 studies on CKD burden conducted across Africa showed very few studies (only 3%) with robust data. 5Stanifer J. W. Jing B. Tolan S. et al. The epidemiology of chronic kidney disease in sub-Saharan Africa: a systematic review and meta-analysis. Lancet Glob Health. 2014; 2: e174-e181Abstract Full Text Full Text PDF PubMed Scopus (287) Google Scholar The provision of adequate resources and a workforce to establish and maintain surveillance systems (e. g. , screening programs and registries) is essential and requires substantial investment. 6Davids M. R. Eastwood J. B. Selwood N. H. et al. A renal registry for Africa: first steps. Clin Kidney J. 2016; 9: 162-167Crossref PubMed Scopus (67) Google Scholar Incorporating kidney disease surveillance parameters in existing chronic disease prevention programs might enhance global efforts toward obtaining high-quality information on kidney disease burden and attendant consequences. Table 1World Bank country group chronic kidney disease gapsCKD careLow-income countries (%) Lower-middle-income countries (%) Upper middle-income countries (%) High-income countries (%) Governmental recognition of CKD as a health priority59501729Government funds all aspects of CKD care13214053Availability of CKD management and referral guidelines (international, national, or regional) 46738397Existence of current CKD detection programs6242432Availability of dialysis registries24487289Availability of academic centers for renal clinical trial management12346263CKD, chronic kidney disease. Data from Bello et al. 4Bello A. K. Levin A. Tonelli M. et al. Global Kidney Health Atlas: a report by the International Society of Nephrology on the current state of organization and structures for kidney care across the globe. https: //www. theisn. org/images/ISNₐdvocacy/GKHAtlasLinkedCompressed1. pdfGoogle Scholar Open table in a new tab CKD, chronic kidney disease. Data from Bello et al. 4Bello A. K. Levin A. Tonelli M. et al. Global Kidney Health Atlas: a report by the International Society of Nephrology on the current state of organization and structures for kidney care across the globe. https: //www. theisn. org/images/ISNₐdvocacy/GKHAtlasLinkedCompressed1. pdfGoogle Scholar In addition to a need for functional surveillance systems, the global importance of kidney disease (including AKI and CKD) is yet to be widely acknowledged, making it a neglected disease on the global policy agenda. For instance, the World Health Organization (WHO) Global Action Plan for the Prevention and Control of Non-Communicable Diseases (NCDs) (2013) focuses on cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes but not kidney disease, despite advocacy efforts by relevant stakeholders such as the International Society of Nephrology and the International Federation of Kidney Foundations through activities such as World Kidney Day. This situation is quite concerning because estimates from the Global Burden of Disease study in 2015 showed that around 1. 2 million people were known to have died of CKD, 7GBD 2015 Mortality and Causes of Death CollaboratorsGlobal, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet. 2016; 388: 1459-1544Abstract Full Text Full Text PDF PubMed Scopus (4096) Google Scholar and more than 2 million people died in 2010 because they had no access to dialysis. It is estimated that another 1. 7 million die from AKI on an annual basis. 8Liyanage T. Ninomiya T. Jha V. et al. Worldwide access to treatment for end-stage kidney disease: a systematic review. Lancet. 2015; 385: 1975-1982Abstract Full Text Full Text PDF PubMed Scopus (1098) Google Scholar, 9Mehta R. L. Cerda J. Burdmann E. A. et al. International Society of Nephrology's 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. Lancet. 2015; 385: 2616-2643Abstract Full Text Full Text PDF PubMed Scopus (603) Google Scholar It is possible, therefore, that kidney disease may contribute to more deaths than the 4 main NCDs targeted by the current NCD Action Plan. Data in recent decades have linked a host of genetic, environmental, sociodemographic, and clinical factors to risk of kidney disease. The population burden of kidney disease is known to correlate with socially defined factors in most societies across the world. This phenomenon is better documented in high-income countries, where racial/ethnic minority groups and people of low socioeconomic status carry a high burden of disease. Extensive data have demonstrated that racial and ethnic minorities (e. g. , African Americans in the United States, Aboriginal groups in Canada and Australia, Indo-Asians in the United Kingdom, and others) are affected disproportionately by advanced and progressive kidney disease. 10Samuel S. M. Palacios-Derflingher L. Tonelli M. et al. Association between First Nations ethnicity and progression to kidney failure by presence and severity of albuminuria. CMAJ. 2014; 186: E86-E94Crossref PubMed Scopus (45) Google Scholar, 11Nicholas S. B. Kalantar-Zadeh K. Norris K. C. Racial disparities in kidney disease outcomes. Semin Nephrol. 2013; 33: 409-415Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar, 12Van den Beukel T. O. de Goeij M. C. Dekker F. W. et al. Differences in progression to ESRD between black and white patients receiving predialysis care in a universal health care system. Clin J Am Soc Nephrol. 2013; 8: 1540-1547Crossref PubMed Scopus (47) Google Scholar The associations of socioeconomic status and risk of progressive CKD and eventual kidney failure also have been well described, with persons of lower socioeconomic status bearing the greatest burden. 13Crews D. C. Gutierrez O. M. Fedewa S. A. et al. Low income, community poverty and risk of end stage renal disease. BMC Nephrol. 2014; 15: 192Crossref PubMed Scopus (62) Google Scholar, 14Garrity B. H. Kramer H. Vellanki K. et al. Time trends in the association of ESRD incidence with area-level poverty in the US population. Hemodial Int. 2016; 20: 78-83Crossref PubMed Scopus (58) Google Scholar Recent works have associated apolipoprotein L1 risk variants15Parsa A. Kao W. H. Xie D. et al. APOL1 risk variants, race, and progression of chronic kidney disease. N Engl J Med. 2013; 369: 2183-2196Crossref PubMed Scopus (530) Google Scholar, 16Peralta C. A. Bibbins-Domingo K. Vittinghoff E. et al. APOL1 genotype and race differences in incident albuminuria and renal function decline. J Am Soc Nephrol. 2016; 27: 887-893Crossref PubMed Scopus (96) Google Scholar with increased kidney disease burden among persons with African ancestry. In Central America and Southeastern Mexico, Mesoamerican nephropathy (also referred to as CKD of unknown causes) has emerged as an important cause of kidney disease. While multiple exposures have been studied for their potential role in CKD of unknown causes, recurrent dehydration and heat stress are common denominators in most cases. 17Correa-Rotter R. Mesoamerican nephropathy or chronic kidney disease of unknown origin. in: García-García G. Agodoa L. Y. Norris K. C. Chronic Kidney Disease in Disadvantaged Populations. Academic Press, Cambridge, MA2017: 221-228Crossref Scopus (28) Google Scholar Other perhaps more readily modifiable risk factors for kidney disease and CKD progression that disproportionately affect socially disadvantaged groups also have been identified, including disparate rates and poor control of clinical risk factors such as diabetes and hypertension, as well as lifestyle behaviors. Diabetes is the leading cause of advanced kidney disease worldwide. 18Levin A. Stevens P. E. Bilous R. W. et al. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1576) Google Scholar In 2016, 1 in 11 adults worldwide had diabetes and more than 80% were living in low- and middle-income countries19Chan J. C. Gregg E. W. Sargent J. Horton R. Reducing global diabetes burden by implementing solutions and identifying gaps: a Lancet Commission. Lancet. 2016; 387: 1494-1495Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar where resources for optimal care are limited. Hypertension is also estimated to affect 1 billion persons worldwide20Kearney P. M. Whelton M. Reynolds K. et al. Global burden of hypertension: analysis of worldwide data. Lancet. 2005; 365: 217-223Abstract Full Text Full Text PDF PubMed Scopus (3983) Google Scholar and is the second leading attributed cause of CKD. 18Levin A. Stevens P. E. Bilous R. W. et al. Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2012 clinical practice guideline for the evaluation and management of chronic kidney disease. Kidney Int Suppl. 2013; 3: 1-150Abstract Full Text Full Text PDF Scopus (1576) Google Scholar Hypertension control is important for slowing CKD progression and decreasing mortality risk among persons with or without CKD. 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Kidney Int. 2013; 84: 457-467Abstract Full Text Full Text PDF PubMed Scopus (425) Google Scholar Because of the complex and costly nature of kidney disease care, its provision is tightly linked with the public policies and financial status of individual countries. For example, gross domestic product is correlated with lower dialysis-to-transplantation ratios, suggesting greater rates of kidney transplantation in more financially solvent nations. In several high-income countries, universal health care is provided by the government and includes CKD and ESRD care. In other countries, such as the United States, ESRD care is publicly for optimal treatment of CKD and its risk factors may not be for persons health and care of with kidney disease is not L. D. R. et al. 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