Global Kidney Health Atlas (GKHA): design and methods
Authors: Aminu K. Bello, David W. Johnson, John Feehally, David Harris, Kailash Jindal, Meaghan Lunney, Ikechi G. Okpechi, Babatunde L. Salako, Natasha Wiebe, Feng Ye, Marcello Tonelli, Adeera Levin
Journal: Kidney International Supplements (2017)

There has been considerable effort within individual countries to improve the care of patients with kidney disease. There has been no concerted attempt to summarize these efforts, and therefore little is known about structuring health systems to facilitate acute kidney injury and chronic kidney disease (CKD) care and integration with national and international noncommunicable disease strategies. As part of the "Closing the Gaps Initiative," the International Society of Nephrology will conduct for the first time a survey of the current state of global kidney care covering both acute kidney injury and CKD and present the results in a Global Kidney Health Atlas. Data will be collected via an online questionnaire and targeted at national nephrology societies, policymakers, and consumer organizations. Individual country information will be provided by at least 3 stakeholders. The Global Kidney Health Atlas will provide concise, relevant, and synthesized information on the delivery of care across different health systems to facilitate understanding of performance variations over time and between countries. First, it will provide an overview of existing CKD care policy and context in the health care system. Second, it will provide an overview of how CKD care is organized in individual countries and a description of relevant CKD epidemiology between countries and regions, focusing on elements that are most germane to service delivery and policy development. Finally, synthesis, comparison, and analysis of individual country/regional data will be provided as a platform for recommendations to policymakers, practitioners, and researchers. There has been considerable effort within individual countries to improve the care of patients with kidney disease. There has been no concerted attempt to summarize these efforts, and therefore little is known about structuring health systems to facilitate acute kidney injury and chronic kidney disease (CKD) care and integration with national and international noncommunicable disease strategies. As part of the "Closing the Gaps Initiative," the International Society of Nephrology will conduct for the first time a survey of the current state of global kidney care covering both acute kidney injury and CKD and present the results in a Global Kidney Health Atlas. Data will be collected via an online questionnaire and targeted at national nephrology societies, policymakers, and consumer organizations. Individual country information will be provided by at least 3 stakeholders. The Global Kidney Health Atlas will provide concise, relevant, and synthesized information on the delivery of care across different health systems to facilitate understanding of performance variations over time and between countries. First, it will provide an overview of existing CKD care policy and context in the health care system. Second, it will provide an overview of how CKD care is organized in individual countries and a description of relevant CKD epidemiology between countries and regions, focusing on elements that are most germane to service delivery and policy development. Finally, synthesis, comparison, and analysis of individual country/regional data will be provided as a platform for recommendations to policymakers, practitioners, and researchers. Chronic kidney disease (CKD) and acute kidney injury (AKI) are both recognized as global public health problems because of associations with adverse health outcomes, high health care costs, and poor quality of life.1Couser W.G. Remuzzi G. Mendis S. Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases.Kidney Int. 2011; 80: 1258-1270Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar, 2James M.T. Hemmelgarn B.R. Tonelli M. Early recognition and prevention of chronic kidney disease.Lancet. 2010; 375: 1296-1309Abstract Full Text Full Text PDF PubMed Scopus (450) Google Scholar, 3Meguid El Nahas A. Bello A.K. Chronic kidney disease: the global challenge.Lancet. 2005; 365: 331-340Abstract Full Text Full Text PDF PubMed Scopus (890) Google Scholar, 4Levey A.S. de Jong P.E. Coresh J. et al.The definition, classification, and prognosis of chronic kidney disease: a KDIGO Controversies Conference report.Kidney Int. 2011; 80: 17-28Abstract Full Text Full Text PDF PubMed Scopus (1514) Google Scholar Moreover, CKD is not only common, harmful, and treatable but is also linked to other major noncommunicable chronic diseases (NCDs) such as diabetes, hypertension, and cardiovascular diseases.5Levey A.S. Eckardt K.U. Tsukamoto Y. et al.Definition and classification of chronic kidney disease: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO).Kidney Int. 2005; 67: 2089-2100Abstract Full Text Full Text PDF PubMed Scopus (2511) Google Scholar, 6Levey A.S. Coresh J. Chronic kidney disease.Lancet. 2012; 379: 165-180Abstract Full Text Full Text PDF PubMed Scopus (1293) Google Scholar As a result of increasing attention to the costs and consequences of CKD and AKI, there has been considerable effort within individual countries to improve the care of this vulnerable population.7Levin A. Steven S. Selina A. et al.Canadian chronic kidney disease clinics: a national survey of structure, function and models of care.Can J Kidney Health Dis. 2014; 1: 29Crossref PubMed Scopus (19) Google Scholar, 8Levin A. Stevens P.E. Summary of KDIGO 2012 CKD Guideline: behind the scenes, need for guidance, and a framework for moving forward.Kidney Int. 2014; 85: 49-61Abstract Full Text Full Text PDF PubMed Scopus (432) Google Scholar, 9Ahlawat R. Tiwari P. D'Cruz S. Singhal R. Prevalence Of Chronic Kidney Disease In India: A Systematic Review And Meta-Analysis Of Observational Studies.Value Health. 2015; 18: A509Abstract Full Text Full Text PDF PubMed Google Scholar, 10Anothaisintawee T. Rattanasiri S. Ingsathit A. Attia J. Thakkinstian A. Prevalence of chronic kidney disease: a systematic review and meta-analysis.Clin Nephrol. 2009; 71: 244-254Crossref PubMed Scopus (28) Google Scholar, 11Coca S.G. Singanamala S. Parikh C.R. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis.Kidney Int. 2012; 81: 442-448Abstract Full Text Full Text PDF PubMed Scopus (1369) Google Scholar, 12Lopez-Vargas P.A. Tong A. Sureshkumar P. et al.Prevention, detection and management of early chronic kidney disease: a systematic review of clinical practice guidelines.Nephrology (Carlton). 2013; 18: 592-604Crossref PubMed Scopus (25) Google Scholar Anecdotal evidence suggests that there is substantial inter- and intracountry as well as regional variability in the approaches taken and the progress made.13Johnson D.W. Atai E. Chan M. et al.KHA-CARI guideline: Early chronic kidney disease: detection, prevention and management.Nephrology (Carlton). 2013; 18: 340-350Crossref PubMed Scopus (130) Google Scholar Because there has been no concerted effort to summarize work and progress to date, little is known about the best way to structure health systems to facilitate CKD and AKI prevention and control or how to integrate these objectives into emerging national and international NCDs management strategies.1Couser W.G. Remuzzi G. Mendis S. Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases.Kidney Int. 2011; 80: 1258-1270Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar, 14Rettig R.A. Norris K. Nissenson A.R. Chronic kidney disease in the United States: a public policy imperative.Clin J Am Soc Nephrol. 2008; 3: 1902-1910Crossref PubMed Scopus (39) Google Scholar, 15Feehally J. Chronic kidney disease: Health burden of kidney disease recognized by UN.Nat Rev Nephrol. 2012; 8: 12-13Crossref Scopus (52) Google Scholar This proposal describes a state-of-the-art knowledge synthesis that will close this knowledge gap and facilitate more coordinated efforts for CKD and AKI prevention and control across the globe.1Couser W.G. Remuzzi G. Mendis S. Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases.Kidney Int. 2011; 80: 1258-1270Abstract Full Text Full Text PDF PubMed Scopus (913) Google Scholar, 15Feehally J. Chronic kidney disease: Health burden of kidney disease recognized by UN.Nat Rev Nephrol. 2012; 8: 12-13Crossref Scopus (52) Google Scholar It describes the development of a systematic data repository, the Global Kidney Health Atlas (GKHA), under the auspices of the International Society of Nephrology (ISN). The GKHA will summarize the structure, format, and outcomes associated with national, regional, and global efforts to improve kidney care in all world regions. This is more germane with the current momentum to push countries toward universal health care (UHC).16McCarthy M. Reducing inequality is crucial to implementing universal health coverage, says WHO report.BMJ. 2013; 347: f5902Crossref PubMed Scopus (2) Google Scholar, 17Groves T. Development of health systems and universal coverage should be evidence based, says WHO.BMJ. 2012; 345: e7530Crossref PubMed Scopus (4) Google Scholar It is unclear what this would mean for kidney care and the readiness of countries and regions on the specifics of care organization to accomplish UHC for the many patients with kidney diseases. This project will determine the global status of kidney care structures and organization toward achieving UHC and devise policy implications for including CKD in the global NCD agenda. The objectives of the GKHA are as follows:1.To provide a high-level overview of the current state of kidney care and how it is organized and structured around the world as well as the burden and consequences of CKD and AKI.2.To conduct a comparative analysis and data synthesis of the collated information across countries and ISN regions to identify key strengths and weaknesses of various systems and explore opportunities for regional networking and collaborations for optimal kidney care around the world.3.To provide a platform for championing the cause of CKD as a leading NCD and assist in advocacy with major stakeholders (World Health Organization, United Nations, Organization for Economic Cooperation and Development, European Union) to increase the profile of CKD as a public health issue.4.To provide the foundation for a global CKD and AKI care surveillance network. We reviewed the mandate provided by the ISN and existing frameworks/initiatives of a similar nature to develop a blueprint/plan of work for the GKHA. The documents reviewed included AKI "0 by 25," World Heart Federation "25 by 25," International Diabetes Federation Global Diabetes Atlas, the WHO Global Atlas on Cardiovascular Disease Prevention and Control as well as several United Nations Policy Documents on strategies and policy for NCDs.18Mehta 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 (605) Google Scholar, 19Huffman M.D. Perel P. Beller G.A. et al.World Heart Federation Emerging Leaders Program: An Innovative Capacity Building Program to Facilitate the 25 x 25 Goal.Glob Heart. 2015; 10: 229-233Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 20Moran A.E. Roth G.A. Narula J. Mensah G.A. 1990-2010 global cardiovascular disease atlas.Glob Heart. 2014; 9: 3-16Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar, 21Linnenkamp U. Guariguata L. Beagley J. et al.The IDF Diabetes Atlas methodology for estimating global prevalence of hyperglycaemia in pregnancy.Diabetes Res Clin Pract. 2014; 103: 186-196Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar, 22Guariguata L. Whiting D. Weil C. Unwin N. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults.Diabetes Res Clin Pract. 2011; 94: 322-332Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar, 23Thomas B. Wulf S. Bikbov B. et al.Maintenance Dialysis throughout the World in Years 1990 and 2010.J Am Soc Nephrol. 2015; 26: 2621-2633Crossref PubMed Scopus (138) Google Scholar, 24The Lancet Diabetes EndocrinologyMonitoring progress in NCDs: key to accountability.Lancet Diabetes Endocrinol. 2015; 3: 159Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar, 25Bello A.K. Levin A. Manns B.J. et al.Effective CKD care in European countries: challenges and opportunities for health policy.Am J Kidney Dis. 2015; 65: 15-25Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar, 26Pearce N. Ebrahim S. McKee M. et al.The road to 25x25: how can the five-target strategy reach its goal?.Lancet Glob Health. 2014; 2: e126-e128Abstract Full Text Full Text PDF PubMed Scopus (35) Google Scholar The work will be carried out across all countries (193 states recognized by the United Nations with a specific focus on 130 countries with ISN-affiliated societies) through the 10 ISN Regional Boards, to be led by a steering committee and work group within the stipulated timeline (Appendix 1):1.Africa2.Eastern and Central Europe3.Latin America and the Caribbean4.Middle East5.North America and the Caribbean6.North and East Asia7.Oceania and South East Asia8.National Independent States and Russia9.South Asia10.Western Europe We will utilize our international contacts, collaborators, and ISN leadership and regional boards to facilitate identification and engagement of project leaders at regional and country levels, which will include individual country nephrology association leadership and opinion leaders across regions and countries. a.To organize and follow up on responses for all countries within the regionb.To serve as a link between the steering committee, ISN, and regional stakeholdersc.To serve as a resource for additional data sources and contacts for surveysd.To identify or serve as an opinion leader on the project for the regione.To identify or serve as a resource person to vet and review regional data a.To organize and follow up on responses within the countryb.To serve as a link between the steering committee, ISN, and country stakeholdersc.To serve as a resource for additional data sources and contacts for surveysd.To identify or serve as a national opinion leadere.To identify or serve as a resource person to vet and review national data The project is approved by the University of Alberta Research Ethics Committee (Protocol number: PRO00063121). The project will involve 2 major elements: (A), desk research and (B), a survey including a mix of quantitative and qualitative methods. The desk research includes a review of published scientific literature, government reports, and other relevant data sources on the various aspects of CKD epidemiology and health systems characteristics using the WHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership) (Table 1, Table 2, Table 3). Although the published literature is important to consider, much of the available evidence is expected to be in the gray literature, including websites and reports with limited circulation. We will engage the various country and regional project leaders to identify these sources and will conduct a detailed gray literature search designed by an expert research librarian. The specific research elements in this section are (i) scoping literature review of national health systems characteristics based on the UHC domains focusing on important elements relevant to CKD care organization and delivery and (ii) systematic review of relevant CKD epidemiology data (burden and outcomes) across countries and regions.Table 1A summary of the project approach: methodology and data sourcesObjectiveMethods/approachCoverage/elementsPrimary data sourcesSecondary data sourcesTo obtain a snapshot of individual country and regional health systems characteristics and specific elements relevant to CKD careScoping reviewSurveyWHO UHC domainsaWHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership).Survey dataInterviewsWHO Global ObservatoryUN, World Bank, and OECD reports on NCDsPublished data/reportsTo obtain data on relevant CKD epidemiology (risk factors, burden, and outcomes) across countries and regionsSystematic reviewsScoping reviewSurveyEstimates of CKD prevalenceEstimates for RRTMortality and disability attributable to CKDCKD risk factorsSurvey dataInterviewsSystematic reviews and consortia publicationsGBD reportsWorld Health ReportWorld Health Indicators ReportsGlobal NCD RepositoryIDF Diabetes AtlasWHF World Cardiovascular Disease AtlasPublished reportsRenal registriesCKD, chronic kidney disease; GBD, global burden of disease; IDF, International Diabetes Federation; NCDs, noncommunicable diseases; OECD, Organization for Economic Cooperation and Development; RRT, renal replacement therapy; UHC, Universal Health Coverage; UN, United Nations; WHF, World Heart Federationa WHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership). Open table in a new tab Table 2General health system characteristics, WHO UHC domains,aWHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership). and relevant data sourcesBuilding blocksIndicators/metricsData sourcesEssential elementsCountry profileTotal population (millions)Annual population growth rate (%)Literacy rate among adults 15 years of age and older (%)Gross national income per capita (PPP int. $)Population living on <$1 (PPP int. $) per day (%)Cellular phone subscribers (per 100 population)Literature reviewsHealth service deliveryDescription of health care system: public/private health insurance funded by national taxation/income contributions covering all/a proportion of the population. Recording of ratio of public/private MDs, renal care centers and/or HD centersLiterature reviewsSurveysInterviewsComprehensivenessAccessibilityCoverageQualityCoordinationEfficiencyAccountabilityHealth work forceDensity of physicians (per 10,000 population)Density of nursing and midwifery personnel (per 10,000 population)Density of pharmaceutical personnel (per 10,000 population)Literature reviewsSurveysInterviewsWHO Global ObservatoryReach and distributionAccessibilityHealth information systemsLiterature reviewsSurveysInterviewsReachScopeEssential medicines and technologiesHospitals (per 100,000 population)Computed tomography units (per million population)Median availability of selected generic medicines in public and private sectors (%)Median consumer price ratio of selected generic medicines in public and private sectorsLiterature reviewsSurveysInterviewsWHO Global ObservatoryHealth financingTotal expenditure on health as a percentage of GDPGeneral government expenditure on health as a percentage of total expenditure on healthPrivate expenditure on health as a percentage of total expenditure on healthGeneral government expenditure on health as a percentage of total government expenditureOut-of-pocket expenditure as a percentage of private expenditure on healthPrivate prepaid plans as a percentage of private expenditure on healthLiterature reviewsWHO Global Observatory DatabaseLeadership and governance (national policies and frameworks)National chronic/noncommunicable disease policy, overarching disease policy targeting long-term conditions including CVD, diabetes, cancer, CKD, etc. (where it exists).Literature reviewsSurveysInterviewsWHO Global ObservatoryWHO NCD strategyCKD, chronic kidney disease; CVD, cardiovascular disease; GDP, gross domestic product; HD, hemodialysis; PPP, purchasing power parity; UHC, universal health coverage, NCD, noncommunicable disease; OECD, Organization for Economic Cooperation and Development.a WHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership). Open table in a new tab Table 3Kidney care–specific elements based on WHO UHC domainsaWHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership). and relevant data sourcesBuilding blocksIndicators/metricsData sourcesEssential elementsHealth service deliveryNumber of health facilities for general CKD careRRT services (e.g., number of health facilities offering HD services per country)Public and privateNondialysis CKD care structureRRT care structureLiterature reviewsSurveysInterviewsAccessibility of dialysis and kidney transplant units to all within the countriesAccess to medicationsReimbursement of treatment and careKidney transplant wait listAccess to psychosocial counseling and supportExistence of patient organizations in each country to facilitate advocacyHealth work forceNo. of nephrologists (per million population)No. of general physicians (per million population)No. of community health workers (per million population)No. of nurses (per million population)Regional distributionNephrology trainees/graduates per yearAvailability of MDTLiterature reviewsSurveysInterviewsWHO Global ObservatoryProfessionals (GPs, nephrologists, diabetologists, endocrinologists, cardiologists, other related disciplines): total and as a ratio to whole population/ or dialysis populationFinancial resources, remuneration and incentives (including those for GPs/specialists to identify and manage CKD patients)Presence of other credentialed health care providers (e.g., nephrology nurses, dietitians)Health information systemsCKD (nondialysis) registryRRT registryLiterature reviewsSurveysInterviewsReachScopeEssential medicines and technologiesACEIs/ARBsStatinsAspirinOther BP medicationsAnemia meds (Epo/iron)CKD-MBD (calcium binders, renagel, cinacalcet)Specific (GN and transplant)Dialysis availability, access, and coverageTransplant availability, access, and coverageLiterature reviewsSurveysInterviewsWHO Global Observatory (for some essential medicines)Health financingTotal expenditure on health for CKDPublic + private contributionsOut-of-pocket payments for essential medicinesOut-of-pocket payments for nondialysis CKD careOut-of-pocket payments for dialysisOut-of-pocket payments for transplantLiterature reviewsSurveysInterviewsWHO Global ObservatoryLeadership and governance(national policies and frameworks)Guidelines/frameworks on CKD careAdvocacy efforts and initiativesEarly detection and prevention programseGFR reportingLiterature reviewsSurveysInterviewsWHO Global ObservatoryWHO NCD StrategyACEIs/ARBs, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers; BP, blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; Epo, erythropoietin; GN, glomerulonephritis; GPs, general practitioners; HD, hemodialysis; MDT, multidisciplinary team; MBD; mineral bone disorder; NCD, noncommunicable disease; RRT, renal replacement therapy; UHC, universal health care.a WHO UHC domains (service delivery, health work force, information systems, medicines and medical products, financing, and leadership). Open table in a new tab CKD, chronic kidney disease; GBD, global burden of disease; IDF, International Diabetes Federation; NCDs, noncommunicable diseases; OECD, Organization for Economic Cooperation and Development; RRT, renal replacement therapy; UHC, Universal Health Coverage; UN, United Nations; WHF, World Heart Federation CKD, chronic kidney disease; CVD, cardiovascular disease; GDP, gross domestic product; HD, hemodialysis; PPP, purchasing power parity; UHC, universal health coverage, NCD, noncommunicable disease; OECD, Organization for Economic Cooperation and Development. ACEIs/ARBs, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers; BP, blood pressure; CKD, chronic kidney disease; eGFR, estimated glomerular filtration rate; Epo, erythropoietin; GN, glomerulonephritis; GPs, general practitioners; HD, hemodialysis; MDT, multidisciplinary team; MBD; mineral bone disorder; NCD, noncommunicable disease; RRT, renal replacement therapy; UHC, universal health care. The steps in data collation are as follows:i.The review will first cover CKD risk factors (biological, behavioral, sociodemographic) available from relevant sources including the WHO Observatory, Organization for Economic Cooperation and Development, World Bank, and related international and regional organizations.ii.We will utilize data from recent Global Burden of Disease (GBD) study work, and the WHO Global Health Repository to highlight estimates for mortality and disability for CKD.27Forouzanfar M.H. Alexander L. Anderson H.R. et al.GBD Risk CollaboratorsGlobal, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2015; 386: 2287-2323Abstract Full Text Full Text PDF PubMed Scopus (1921) Google Scholar, 28Murray C.J. Barber R.M. Foreman K.J. et al.Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition.Lancet. 2015; 386: 2145-2191Abstract Full Text Full Text PDF PubMed Scopus (1336) Google Scholar, 29GBD 2013 Mortality and Causes of Death CollaboratorsGlobal, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.Lancet. 2015; 385: 117-171Abstract Full Text Full Text PDF PubMed Scopus (5381) Google Scholariii.We will search published and unpublished documents from international organizations/bodies (e.g., Organization for Economic Cooperation and Development, WHO, UN, Commonwealth Fund, World Bank, European Union and its affiliates) and reports published by national governments (and occasionally regional governments within countries) on the organization and delivery of CKD care.iv.Additional literature will be identified based on guidance from key stakeholders (opinion leaders and national nephrology society/ISN leaders). We will consult national nephrology societies and ISN regional boards to elucidate alternative data sources relevant to their own countries and regions.v.Data will be stratified and extracted by country/region into standard data extraction files, with each data source identified as regional, national, and subnational (e.g., within-country regions, provinces, states, counties) considering potential bias and uncertainties in data sources that were not representative of their regional or national populations.vi.We will utilize various sources and a comprehensive search strategy developed in conjunction with an expert librarian. For this aspect of the project, we will leverage the methodology applied by the International Diabetes Federation to generate the Diabetes Atlas.22Guariguata L. Whiting D. Weil C. Unwin N. The International Diabetes Federation diabetes atlas methodology for estimating global and national prevalence of diabetes in adults.Diabetes Res Clin Pract. 2011; 94: 322-332Abstract Full Text Full Text PDF PubMed Scopus (184) Google Scholar Briefly, the population-based data on CKD burden will be obtained from a systematic literature search of original publications and existing reviews on the CKD burden across the world.30Noubiap J.J. Naidoo J. Kengne A.P. Diabetic nephropathy in Africa: a systematic review.World J Diabetes. 2015; 6: 759-773Crossref PubMed Scopus (16) Google Scholar, 31Stanifer 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, 32Liyanage 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 (1099) Google Scholar We will search PubMed, Google Scholar, CINAHL, Embase, Cochrane Database of Systematic Reviews, and WHO Global InfoBase to identify all original publications reporting the prevalence of CKD in the adult general population. Because the Kidney Disease Outcomes Quality Initiative published a guideline on CKD definitions in 2002, we will explore articles published from January 1, 2003 to December 31, 2016. We will consider literature published in English and other languages that examined CKD and/or albuminuria in a community setting. If multiple studies are identified that used the same population or data source, the first original publication and/or the most recent (as appropriate) will be selected for review. Studies will be included if they were peer-reviewed and meet the following criteria:1.Report a measure of population-based prevalence for CKD and/or albuminuria in the general population.2.Enrolled adults aged 18 years of age and older.3.Recruited subjects from a community-based population sample.4.Present detailed methodology and results. Regional and country nephrology society leaders will also be asked to identify additional data sources on gray literature from surveys and/or prevention programs not yet in the public domain. The literature search will be performed by 2 investigators, and any study that is judged relevant based on its title will be retrieved in abstract form and, if relevant