The global burden of chronic kidney disease
Authors: Paul Cockwell, Lori-Ann Fisher
Journal: The Lancet (2020)

Chronic kidney disease (CKD) is a non-communicable disease usually caused by diabetes and hypertension.1Webster AC Nagler EV Morton RL Masson P Chronic kidney disease.Lancet. 2017; 389: 1238-1252Summary Full Text Full Text PDF PubMed Scopus (1568) Google Scholar Cardiovascular disease is the major cause of the early morbidity and mortality sustained by patients with CKD. The severity of CKD can be quantified by a low serum creatinine-based estimated glomerular filtration rate (eGFR), which indicates excretory kidney function, and raised urinary albumin measured by the urinary albumin-to-creatinine ratio (ACR), which is a marker of kidney damage.2van der Velde M Matsushita K Coresh J et al.Lower estimated glomerular filtration rate and higher albuminuria are associated with all-cause and cardiovascular mortality: a collaborative meta-analysis of high-risk population cohorts.Kidney Int. 2011; 79: 1341-1352Summary Full Text Full Text PDF PubMed Scopus (641) Google Scholar The Kidney Disease: Improving Global Outcomes classification system for staging CKD is based on eGFR and ACR and is widely used in clinical practice. In The Lancet, the Global Burden of Disease (GBD) Chronic Kidney Disease Collaboration report a comprehensive analysis of the global prevalence and burden of CKD.3GBD Chronic Kidney Disease CollaborationGlobal, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2020; (published online Feb 13. https://doi.org/10.1016/S0140-6736(20)30045-3.)Google Scholar The researchers used established GBD methodology in their analysis of data for 1990–2017 from 195 countries. Complex statistical modelling was applied to minimise uncertainty in primary data, and predictive covariates and geographical proximity estimates were used to maximise accuracy for countries with limited primary data. In 2017, the global prevalence of CKD was 9·1% (95% uncertainty interval [UI] 8·5 to 9·8), which is roughly 700 million cases. Since 1990, the prevalence of CKD has increased by 29·3% (26·4 to 32·6), but age-standardised prevalence has remained unchanged during this period (1·2%, −1·1 to 3·5). A substantial increase was noted in age-standardised incidence of end-stage kidney disease (ESKD) treated by renal replacement therapy, with dialysis and kidney transplantation increasing by 43·1% (95% UI 40·5 to 45·8) and 34·4% (29·7 to 38·9), respectively. The global increase in mortality from CKD since 1990 was 41·5% (95% UI 35·2 to 46·5), such that mortality from CKD, and cardiovascular disease deaths attributable to impaired kidney function (a term used to describe a low eGFR or elevated ACR without treatment by renal replacement therapy) caused 4·6% (4·3 to 5·0) of global deaths in 2017, making CKD the 12th leading cause of death globally in 2017, an increase from 17th in 1990. Age-standardised mortality remained unchanged, with a 2·8% change (95% UI −1·5 to 6·3) from 1990 to 2017. Large between-region and between-country variations were noted in deaths from CKD; for example, in central Latin America, central Asia, and high-income North America, CKD mortality increased by around 60%. In central and Andean Latin America, CKD was, respectively, the second and fifth ranked cause of death in 2017. Overall, these GBD data are a stark confirmation that the global burden of CKD is increasingly carried by countries in low and middle Socio-demographic Index (SDI) quintiles. The differential changes in prevalence of and mortality from CKD are likely to be multifactorial. Some countries showed increases compared with neighbouring countries with similar demographics, indicating increased recognition and recording of CKD and mortality from this disease. Survival is also extended (with population ageing) in countries in lower SDI quintiles, with an epidemiological shift in mortality from communicable diseases to non-communicable diseases, with major increases in the prevalence of diabetes and hypertension.4NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants.Lancet. 2016; 387: 1513-1530Summary Full Text Full Text PDF PubMed Scopus (2300) Google Scholar, 5NCD Risk Factor Collaboration (NCD-RisC)Worldwide trends in blood pressure from 1975 to 2015: a pooled analysis of 1479 population-based measurement studies with 19·1 million participants.Lancet. 2017; 389: 37-55Summary Full Text Full Text PDF PubMed Scopus (1315) Google Scholar In some regions, changes might also be seen in disease epidemiology; for example, in some Latin American countries, CKD of unknown cause (eg, mesoamerican nephropathy) is prevalent.6Gonzalez-Quiroz M Pearce N Caplin B Nitsch D What do epidemiological studies tell us about chronic kidney disease of undetermined cause in Meso-America? A systematic review and meta-analysis.Clin Kidney J. 2018; 11: 496-506Crossref PubMed Scopus (55) Google Scholar Disability-associated life-years (DALYs) caused by CKD, or cardiovascular disease and gout attributable to impaired kidney function, varied more than 15-fold between countries. Generally, regions and countries within the lower SDI quintiles sustained the highest rates of DALYs. Years living with disability (YLDs) accounted for only 20·3% (95% UI 15·9–24·6) of the total CKD DALYs, probably because most patients had mild-to-moderate CKD (ie, stages 1–3), a level of disease at which specific functional impairment is uncommon. These GBD data demand careful reading by policy makers and clinicians. CKD-attributable morbidity and mortality follow the paradigm for chronic disease, whereby access to identification and management is dependent on income and geography. Patients living in countries in low and middle SDI quintiles who do not die during progression of CKD will typically die within months when they reach ESKD, because renal replacement therapy is not available or dialysis is inadequate. Kidney transplantation, the best health-preserving and economic treatment for ESKD, only accounts for a fifth of renal replacement therapy, and programmes are underdeveloped in most countries. The global age-standardised mortality rate for CKD is not declining, unlike those for other important non-communicable diseases.7GBD 2017 Causes of Death CollaboratorsGlobal, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the Global Burden of Disease Study 2017.Lancet. 2018; 392: 1736-1788Summary Full Text Full Text PDF PubMed Scopus (3474) Google Scholar Interventions to slow kidney disease progression require early testing of people at risk by measurement of eGFR and ACR. Even in high-income countries, ACR testing is generally not done,8Kim LG Cleary F Wheeler DC et al.How do primary care doctors in England and Wales code and manage people with chronic kidney disease? Results from the National Chronic Kidney Disease Audit.Nephrol Dial Transplant. 2018; 33: 1373-1379Crossref PubMed Scopus (24) Google Scholar despite being a major independent risk factor for CKD progression and cardiovascular disease events.9Hallan SI Matsushita K Sang Y et al.Age and association of kidney measures with mortality and end-stage renal disease.JAMA. 2012; 308: 2349-2360Crossref PubMed Scopus (428) Google Scholar Inexpensive interventions for diabetes, hypertension, and CKD can have a substantial effect on clinical and societal outcomes.10Chen TK Knicely DH Grams ME Chronic kidney disease diagnosis and management: a review.JAMA. 2019; 322: 1294-1304Crossref PubMed Scopus (385) Google Scholar Supporting countries to develop sustainable and affordable health-care infrastructure for CKD and other non-communicable diseases, from public health legislation to population-based identification and management programmes, is a global priority.11Di Cesare M Khang Y-H Asaria P et al.Inequalities in non-communicable diseases and effective responses.Lancet. 2013; 381: 585-597Summary Full Text Full Text PDF PubMed Scopus (420) Google Scholar, 12Levin A Tonelli M Bonventre J et al.Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy.Lancet. 2017; 390: 1888-1917Summary Full Text Full Text PDF PubMed Scopus (489) Google Scholar PC declares honoraria for educational seminars from NAPP Pharmaceuticals, outside of the area of work commented on here. L-AF declares no competing interests. Global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017Kidney disease has a major effect on global health, both as a direct cause of global morbidity and mortality and as an important risk factor for cardiovascular disease. CKD is largely preventable and treatable and deserves greater attention in global health policy decision making, particularly in locations with low and middle SDI. Full-Text PDF Open Access