Mind the gap in kidney care: translating what we know into what we do
Authors: Valerie A. Luyckx, Katherine R. Tuttle, Dina Abdellatif, Ricardo Correa-Rotter, Winston W.S. Fung, Agnès Haris, Li-Li Hsiao, Makram Khalife, Latha A. Kumaraswami, Fiona Loud, Vasundhara Raghavan, Stefanos Roumeliotis, Marianella Sierra, Ifeoma Ulasi, Bill Wang, Siu-Fai Lui, Vassilios Liakopoulos, Alessandro Balducci, Alessandro Balducci, Vassilios Liakopoulos, Li-Li Hsiao, Ricardo Correa-Rotter, Ifeoma Ulasi, Latha Kumaraswami, Siu Fai Lui, Dina Abdellatif, Ágnes Haris
Journal: Kidney International (2024)

Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay. Historically, it takes an average of 17 years to move new treatments from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. The time is now to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions worldwide are diagnosed, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because in the early stages it is often silent. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from patient to clinician to health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay. At least 1 in 10 people worldwide is living with kidney disease.1Jager K.J. Kovesdy C. Langham R. et al.A single number for advocacy and communication-worldwide more than 850 million individuals have kidney diseases.Kidney Int. 2019; 96: 1048-1050Abstract Full Text Full Text PDF PubMed Google Scholar According to the Global Burden of Disease study, in 2019, >3.1 million deaths were attributed to kidney dysfunction, making it the seventh leading risk factor for death worldwide (Figure 1 and Supplementary Figure S1).2Institute for Health Metrics and Evaluation (IHME)GBD compare data visualization.http://vizhub.healthdata.org/gbd-compareDate accessed: November 18, 2023Google Scholar However, global mortality from all kidney diseases may actually range between 5 and 11 million per year if the estimated lives lost, especially in lower-resource settings, from acute kidney injury and from lack of access to kidney replacement therapy for kidney failure (KF) are also counted.3Luyckx V.A. Tonelli M. Stanifer J.W. The global burden of kidney disease and the sustainable development goals.Bull World Health Organ. 2018; 96: 414-422DCrossref PubMed Scopus (461) Google Scholar These high global death rates reflect disparities in prevention, early detection, diagnosis, and treatment of chronic kidney disease (CKD).4International Society of NephrologyISN Global Kidney Health Atlas.3rd ed. 2023https://www.theisn.org/initiatives/global-kidney-health-atlas/Date accessed: November 18, 2023Google Scholar Death rates from CKD are especially prominent in some regions, and particularly high in Central Latin America and Oceania (islands of the South Pacific Ocean), indicating the need for urgent action.5GBD 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; 395: 709-733Abstract Full Text Full Text PDF PubMed Scopus (2787) Google Scholar CKD also poses a significant global economic burden, with costs increasing exponentially as CKD progresses, not only because of the costs of dialysis and transplantation, but also because of the multiple comorbidities and complications that accumulate over time.6Vanholder R. Annemans L. Brown E. et al.Reducing the costs of chronic kidney disease while delivering quality health care: a call to action.Nat Rev Nephrol. 2017; 13: 393-409Crossref PubMed Scopus (187) Google Scholar,7Nguyen-Thi H.Y. Le-Phuoc T.N. Tri Phat N. et al.The economic burden of chronic kidney disease in Vietnam.Health Serv Insights. 2021; 1411786329211036011Google Scholar In the United States, Medicare fee-for-service spending for all beneficiaries with CKD was $86.1 billion in 2021 (22.6% of the total expenditure).8US Renal Data SystemHealthcare expenditures for persons with CKD.https://usrds-adr.niddk.nih.gov/2023/chronic-kidney-disease/6-healthcare-expenditures-for-persons-with-ckdDate accessed: November 18, 2023Google Scholar Data from many lower-resource settings are absent, where most costs are paid for out of pocket. A recent study from Vietnam reported that the cost of CKD per patient was higher than the gross domestic product per capita.7Nguyen-Thi H.Y. Le-Phuoc T.N. Tri Phat N. et al.The economic burden of chronic kidney disease in Vietnam.Health Serv Insights. 2021; 1411786329211036011Google Scholar In Australia, it has been estimated that early diagnosis and prevention of CKD could save the health system $10.2 billion over 20 years.9Kidney Health AustraliaTransforming Australia's kidney health: a call to action for early detection and treatment of chronic kidney disease.https://kidney.org.au/uploads/resources/Changing-the-CKD-landscape-Economic-benefits-of-early-detection-and-treatment.pdfDate accessed: January 16, 2024Google Scholar Although there is regional variation in the causes of CKD, the risk factors with the highest population-attributable factors for age-standardized CKD-related disease-adjusted life years were as follows: high blood pressure (51.4%), high fasting plasma glucose level (30.9%), and high body mass index (26.5%).10Ke C. Liang J. Liu M. et al.Burden of chronic kidney disease and its risk-attributable burden in 137 low-and middle-income countries, 1990-2019: results from the global burden of disease study 2019.BMC Nephrol. 2022; 23: 17Crossref PubMed Scopus (0) Google Scholar These risk factors are also global leading risk factors for death (Figure 1). Only 40% and 60% of those with hypertension and diabetes, respectively, are aware of their diagnosis, and far smaller proportions are receiving treatment and at target goals.11Gregg E.W. Buckley J. Ali M.K. et al.Improving health outcomes of people with diabetes: target setting for the WHO Global Diabetes Compact.Lancet. 2023; 401: 1302-1312Abstract Full Text Full Text PDF PubMed Scopus (16) Google Scholar,12Geldsetzer P. Manne-Goehler J. Marcus M.E. et al.The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1.1 million adults.Lancet. 2019; 394: 652-662Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar Moreover, at least 1 in 5 people with hypertension and 1 in 3 people with diabetes also have CKD.13Chu L. Bhogal S.K. Lin P. et al.AWAREness of Diagnosis and Treatment of Chronic Kidney Disease in Adults With Type 2 Diabetes (AWARE-CKD in T2D).Can J Diabetes. 2022; 46: 464-472Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar A large proportion of CKD can be prevented through healthy lifestyles, prevention and control of risk factors, avoidance of acute kidney injury, optimization of maternal and child health, mitigation of climate change, and addressing social and structural determinants of health.3Luyckx V.A. Tonelli M. Stanifer J.W. The global burden of kidney disease and the sustainable development goals.Bull World Health Organ. 2018; 96: 414-422DCrossref PubMed Scopus (461) Google Scholar Nevertheless, the benefits of some of these measures may only be seen in generations to come. In the meantime, early diagnosis and risk stratification create opportunities to institute therapies to slow, halt, or even reverse CKD.14Levin 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: 1888-1917Abstract Full Text Full Text PDF PubMed Scopus (615) Google Scholar Concerningly, CKD awareness was strikingly low among individuals with kidney dysfunction, with ≈80% to 95% of patients being unaware of their diagnosis across world regions (Figure 2).15Stengel B. Muenz D. Tu C. et al.Adherence to the Kidney Disease: Improving Global Outcomes CKD guideline in nephrology practice across countries.Kidney Int Rep. 2021; 6: 437-448Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar, 16Chu C.D. Chen M.H. McCulloch C.E. et al.Patient awareness of CKD: a systematic review and meta-analysis of patient-oriented questions and study setting.Kidney Med. 2021; 3: 576-585.e1Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 17Ene-Iordache B. Perico N. Bikbov B. et al.Chronic kidney disease and cardiovascular risk in six regions of the world (ISN-KDDC): a cross-sectional study.Lancet Global Health. 2016; 4: e307-e319Abstract Full Text Full Text PDF PubMed Google Scholar, 18Gummidi B. John O. Ghosh A. et al.A systematic study of the prevalence and risk factors of CKD in Uddanam, India.Kidney Int Rep. 2020; 5: 2246-2255Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 19Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127PubMed Google Scholar, 20Nicholas S.B. Daratha K.B. Alicic R.Z. et al.Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020.Diabetes Obes Metab. 2023; 25: 2970-2979Crossref Scopus (4) Google Scholar People are dying because of missed opportunities to detect CKD early and deliver optimal care! More important, CKD is a major risk factor for cardiovascular disease, and as kidney disease progresses, cardiovascular death and KF become competing risks.21Grams M.E. Yang W. Rebholz C.M. et al.Risks of adverse events in advanced CKD: the Chronic Renal Insufficiency Cohort (CRIC) study.Am J Kidney Dis. 2017; 70: 337-346Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Indeed, the Global Burden of Disease study data from 2019 showed that more people died of cardiovascular disease attributed to kidney dysfunction (1.7 million people) than from CKD itself (1.4 million people).2Institute for Health Metrics and Evaluation (IHME)GBD compare data visualization.http://vizhub.healthdata.org/gbd-compareDate accessed: November 18, 2023Google Scholar Therefore, cardiovascular disease care must also be a priority for people with CKD. Strategies to prevent and treat CKD have been built on a strong evidence base over the past 3 decades (Figure 3).19Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127PubMed Google Scholar,22Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease. Kidney Int. https://doi.org/10.1016/j.kint.2023.10.018Google Scholar Clinical practice guidelines for CKD are clear; however, adherence to these guidelines is suboptimal (Figure 2).15Stengel B. Muenz D. Tu C. et al.Adherence to the Kidney Disease: Improving Global Outcomes CKD guideline in nephrology practice across countries.Kidney Int Rep. 2021; 6: 437-448Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,19Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127PubMed Google Scholar,20Nicholas S.B. Daratha K.B. Alicic R.Z. et al.Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020.Diabetes Obes Metab. 2023; 25: 2970-2979Crossref Scopus (4) Google Scholar Regardless of the cause, control of major risk factors, particularly diabetes and hypertension, forms the foundation of optimal care for CKD.19Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127PubMed Google Scholar,23Kidney Disease: Improving Global Outcomes (KDIGO) Blood Pressure Work GroupKDIGO 2021 clinical practice guideline for the management of blood pressure in chronic kidney disease.Kidney Int. 2021; 99: S1-S87PubMed Google Scholar Beyond lifestyle changes and risk factor control, the initial pharmacologic classes of agents proven to provide kidney protection were the renin-angiotensin-aldosterone system inhibitors in the form of angiotensin-converting enzyme inhibitors (ACEIs) and the angiotensin receptor blockers.14Levin 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: 1888-1917Abstract Full Text Full Text PDF PubMed Scopus (615) Google Scholar,19Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127PubMed Google Scholar However, despite decades of knowledge that these medications have important protective effects on kidney and heart function in people with CKD, their use has remained low based on real-world data from electronic health records (Figure 2). For example, in the United States, ACEI or angiotensin receptor blocker use was reported in the range of 20% to 40% at ≥15 years after the last approvals of these agents for patients with CKD and type 2 diabetes.24Tuttle K.R. Alicic R.Z. Duru O.K. et al.Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD registry.JAMA Netw Open. 2019; 2e1918169Crossref PubMed Scopus (113) Google Scholar Although more recent data show improvement in prescribing rates to 70% in this population, just 40% persist on an ACEI or angiotensin receptor blocker for at least 90 days.20Nicholas S.B. Daratha K.B. Alicic R.Z. et al.Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020.Diabetes Obes Metab. 2023; 25: 2970-2979Crossref Scopus (4) Google Scholar These data illustrate gaps in both prescribing kidney protective medication and continuity of care over time, potentially related to cost, lack of patient education, polypharmacy, and adverse effects.25Ismail W.W. Witry M.J. Urmie J.M. The association between cost sharing, prior authorization, and specialty drug utilization: a systematic review.J Manag Care Spec Pharm. 2023; 29: 449-463Google Scholar Although initial enthusiasm for sodium-glucose cotransporter 2 (SGLT2) inhibitors focused on their benefits for diabetes and cardiovascular disease, unprecedented therapeutic benefits have clearly been observed for CKD as well. The relative risk reductions with SGLT2 inhibitors approach 40% for substantial decline in estimated glomerular filtration rate, KF, and death in populations with CKD of several causes, heart failure, or high cardiovascular disease risk.26Heerspink H.J.L. Vart P. Jongs N. et al.Estimated lifetime benefit of novel pharmacological therapies in patients with type 2 diabetes and chronic kidney disease: a joint analysis of randomized controlled clinical trials.Diabetes Obes Metab. 2023; 25: 3327-3336Crossref Scopus (5) Google Scholar,27Nuffield Department of Population Health Renal Studies GroupSGLT2 Inhibitor Meta-Analysis Cardio-Renal Trialists' Consortium. Impact of diabetes on the effects of sodium glucose co-transporter-2 inhibitors on kidney outcomes: collaborative meta-analysis of large placebo-controlled trials.Lancet. 2022; 400: 1788-1801Abstract Full Text Full Text PDF PubMed Scopus (200) Google Scholar These benefits accrued on top of standard-of-care risk factor management and renin-angiotensin-aldosterone system inhibitor. Risks of heart failure, cardiovascular death, and all-cause mortality were also reduced in patients with CKD.26Heerspink H.J.L. Vart P. Jongs N. et al.Estimated lifetime benefit of novel pharmacological therapies in patients with type 2 diabetes and chronic kidney disease: a joint analysis of randomized controlled clinical trials.Diabetes Obes Metab. 2023; 25: 3327-3336Crossref Scopus (5) Google Scholar Addition of SGLT2 inhibitor to renin-angiotensin-aldosterone system inhibitors could delay the need for kidney replacement therapy by several years, depending on when they are started.28Fernández-Fernandez B. Sarafidis P. Soler M.J. et al.EMPA-KIDNEY: expanding the range of kidney protection by SGLT2 inhibitors.Clin Kidney J. 2023; 16: 1187-1198Crossref Google Scholar Moreover, for every 1000 patients with CKD treated with an SGLT2 inhibitor on top of standard therapy, 83 deaths, 19 heart failure hospitalizations, 51 dialysis initiations, and 39 episodes of acute kidney function worsening can be prevented.29McEwan P. Boyce R. Sanchez J.J.G. et al.Extrapolated longer-term effects of the DAPA-CKD trial: a modelling analysis.Nephrol Dial Transplant. 2023; 38: 1260-1270Crossref Scopus (3) Google Scholar Concerningly, marked underuse of these and other guideline-recommended therapies, including SGLT2 inhibitors, persists (Figure 2).20Nicholas S.B. Daratha K.B. Alicic R.Z. et al.Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020.Diabetes Obes Metab. 2023; 25: 2970-2979Crossref Scopus (4) Google Scholar,24Tuttle K.R. Alicic R.Z. Duru O.K. et al.Clinical characteristics of and risk factors for chronic kidney disease among adults and children: an analysis of the CURE-CKD registry.JAMA Netw Open. 2019; 2e1918169Crossref PubMed Scopus (113) Google Scholar In the CURE-CKD registry, only 5% and 6.3% of eligible patients with CKD and diabetes, respectively, continued on SGLT2 inhibitor and glucagon-like peptide-1 receptor agonist at 90 days.18Gummidi B. John O. Ghosh A. et al.A systematic study of the prevalence and risk factors of CKD in Uddanam, India.Kidney Int Rep. 2020; 5: 2246-2255Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar Notably, lack of commercial health insurance and treatment in community-based versus academic institutions were associated with lower likelihoods of SGLT2 inhibitor , ACEI, or angiotensin receptor blocker prescriptions among patients with diabetes and CKD.20Nicholas S.B. Daratha K.B. Alicic R.Z. et al.Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020.Diabetes Obes Metab. 2023; 25: 2970-2979Crossref Scopus (4) Google Scholar In low- or middle-income countries (LMICs), the gap between evidence and implementation is even wider given the high cost and inconsistent availability of these medications, despite availability of generics.30Vanholder R. Annemans L. Braks M. et al.Inequities in kidney health and kidney care.Nat Rev Nephrol. 2023; 19: 694-708Crossref Scopus (1) Google Scholar Such gaps in delivering optimal treatment for CKD are unacceptable. In addition to the SGLT2 inhibitors, nonsteroidal mineralocorticoid receptor antagonists have been demonstrated to reduce the risks of CKD progression, KF, cardiovascular events, and deaths, on top of the standard of care with renin-angiotensin-aldosterone system inhibitors, in type 2 diabetes.31Agarwal R. Filippatos G. Pitt B. et al.Cardiovascular and kidney outcomes with finerenone in patients with type 2 diabetes and chronic kidney disease: the FIDELITY pooled analysis.Eur Heart J. 2022; 43: 474-484Crossref PubMed Scopus (297) Google Scholar A growing portfolio of promising therapeutic options is on the horizon with glucagon-like peptide-1 receptor agonists (NCT03819153, NCT04865770), aldosterone synthase inhibitors (NCT05182840), and dual-to-triple incretins (Supplementary Table S1).26Heerspink H.J.L. Vart P. Jongs N. et al.Estimated lifetime benefit of novel pharmacological therapies in patients with type 2 diabetes and chronic kidney disease: a joint analysis of randomized controlled clinical trials.Diabetes Obes Metab. 2023; 25: 3327-3336Crossref Scopus (5) Google Scholar,32Tuttle K.R. Bosch-Traberg H. Cherney D.Z.I. et al.Post hoc analysis of SUSTAIN 6 and PIONEER 6 trials suggests that people with type 2 diabetes at high cardiovascular risk treated with semaglutide experience more stable kidney function compared with placebo.Kidney Int. 2023; 103: 772-781Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Furthermore, the evidence is already clear that in patients with CKD and diabetes, glucagon-like peptide-1 receptor agonists reduce cardiovascular events, are safe and effective glucose-lowering therapies, and aid with weight loss.32Tuttle K.R. Bosch-Traberg H. Cherney D.Z.I. et al.Post hoc analysis of SUSTAIN 6 and PIONEER 6 trials suggests that people with type 2 diabetes at high cardiovascular risk treated with semaglutide experience more stable kidney function compared with placebo.Kidney Int. 2023; 103: 772-781Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Historically, it has taken an average of 17 years to move new treatments from clinical evidence to daily practice.33Rubin R. It takes an average of 17 years for evidence to change practice-the burgeoning field of implementation science seeks to speed things up.JAMA. 2023; 329: 1333-1336Crossref Scopus (9) Google Scholar With millions of people with CKD dying each year, this is far too long to wait. Since the launch of the World Health Organization Action Plan for Non-Communicable Diseases (NCDs) in 2013, there has been global progress in the proportion of countries with a national NCD action plan and dedicated NCD units.34World Health OrganisationMid-point evaluation of the implementation of the WHO global action plan for the prevention and control of noncommunicable diseases 2013–2020 (NCD-GAP).https://cdn.who.int/media/docs/default-source/documents/about-us/evaluation/ncd-gap-final-report.pdf?sfvrsn=55b22b89_5&download=trueDate accessed: November 18, 2023Google Scholar However, CKD is only incorporated into NCD strategies in approximately one-half of countries.4International Society of NephrologyISN Global Kidney Health Atlas.3rd ed. 2023https://www.theisn.org/initiatives/global-kidney-health-atlas/Date accessed: November 18, 2023Google Scholar Policies are required to integrate kidney care within essential health packages under universal health coverage (Figure 4).30Vanholder R. Annemans L. Braks M. et al.Inequities in kidney health and kidney care.Nat Rev Nephrol. 2023; 19: 694-708Crossref Scopus (1) Google Scholar Multisectoral policies must also address the social determinants of health, which are major amplifiers of CKD risk and severity, limiting people's opportunities to improve their health.3Luyckx V.A. Tonelli M. Stanifer J.W. The global burden of kidney disease and the sustainable development goals.Bull World Health Organ. 2018; 96: 414-422DCrossref PubMed Scopus (461) Google Scholar Lack of investment in kidney health promotion, along with primary and secondary prevention of kidney disease, hinders progress.14Levin 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: 1888-1917Abstract Full Text Full Text PDF PubMed Scopus (615) Google Scholar Two major goals of universal health coverage are to achieve coverage of essential health services and reduce financial hardship imposed by health care. However, universal health coverage alone is insufficient to ensure adequate access to kidney care.3Luyckx V.A. Tonelli M. Stanifer J.W. The global burden of kidney disease and the sustainable development goals.Bull World Health Organ. 2018; 96: 414-422DCrossref PubMed Scopus (461) Google Scholar Health systems must be strengthened and quality of care must also be prioritized, as poor quality care contributes to more deaths than lack of access in low-resource settings.35Kruk M.E. Gage A.D. Joseph N.T. et al.Mortality due to low-quality health systems in the universal health coverage era: a systematic analysis of amenable deaths in 137 countries.Lancet. 2018; 392: 2203-2212Abstract Full Text Full Text PDF PubMed Scopus (443) Google Scholar Quality care requires a well-trained health care workforce, sustainable availability of accurate diagnostics, reliable infrastructure, and medication supplies and should be monitored in an ongoing process of quality improvement (Figure 4). The quality of medications, especially in LMICs, may be an additional barrier to successful management of CKD.36Kingori P. Peeters Grietens K. Abimbola S. et al.Uncertainties about the quality of medical products globally: lessons from multidisciplinary research.BMJ Glob Health. 2023; 6e012902Crossref Scopus (1) Google Scholar Regulation and monitoring of drug manufacturing and quality standards are important to ensure safe and effective therapies. Strategies to support regulation and quality assurance will need to be developed in local contexts and guidance, as outlined elsewhere.37Pan American Health Organization Quality control of medicines.https://www.paho.org/en/topics/quality-control-medicinesDate accessed: November 18, 2023Google Scholar Establishing a credible case for CKD detection and management based on risks, interventions and outcomes, and costs, based on real-world data, will help to translate theoretical cost-effectiveness (currently established primarily in high-income countries with minimal data from elsewhere) into economic reality.30Vanholder R. Annemans L. Braks M. et al.Inequities in kidney health and kidney care.Nat Rev Nephrol. 2023; 19: 694-708Crossref Scopus (1) Google Scholar,38Tuttle K.R. Wong L. St Peter W. et al.Moving from evidence to implementation of breakthrough therapies for diabetic kidney disease.Clin J Am Soc Nephrol. 2022; 17: 1092-1103Crossref PubMed Scopus (19) Google Scholar Screening should include evaluation of risk factors for CKD, eliciting a family history, recognizing potential symptoms (usually advanced—fatigue, poor appetite, edema, itching etc.), and measuring blood pressure, serum creatinine, urinalysis, and urine albumin/protein to creatinine ratios, as outlined in established guidelines.19Kidney Disease: Improving Global Outcomes (KDIGO) Diabetes Work GroupKDIGO 2022 Clinical Practice Guideline for Diabetes Management in Chronic Kidney Disease.Kidney Int. 2022; 102: S1-S127PubMed Google Scholar,39Kalyesubula R. Conroy A.L. Calice-Silva V. et al.Screening for kidney disease in low- and middle-income countries.Semin Nephrol. 2022; 42151315Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar Addressing CKD upstream beginning in primary care should lower costs over time by reducing CKD complications and KF. Medications required for kidney care are already included in the World Health Organization Essential Medication List (Table 1). These must be provided at national levels under universal health coverage.40Francis A. Abdul Hafidz M.I. Ekrikpo U.E. et al.Barriers to accessing essential medicines for kidney disease in low- and lower middle-income countries.Kidney Int. 2022; 102: 969-973Abstract Full Text Full Text PDF Scopus (0) Google Scholar Pharmaceutical companies should provide these at affordable prices.Table 1Essential medicines for patients with kidney diseaseMedication/technologyExampleReasonOn WHO model list of essential medicinesACE inhibitorEnalapril, lisinoprilDelays CKD progression, benefits cardiovascular disease and strokeYesAngiotensin receptor blockerLosartan, telmisartanDelays CKD progression, cardiovascular disease, and strokeYesCalcium channel blockerAmlodipine, verapamilBlood pressure controlYesLoop diureticsFurosemide, torsemideGood when GFR is low, good for heart failureYesThiazide diureticsHydrochlorothiazide, metolazone, indapamideGood for BP, especially in the Black populationYesSGLT2 inhibitorEmpagliflozin, canagliflozin, dapagliflozinDiabetes control, delays CKD progression, cardiovascular disease, and deathYesGLP1 agonistSemaglutideDiabetes control, weight lossNoMineralocorticoid inhibitorSpironolactone, finerenoneDelays CKD progression, reduces heart failure riskCaution: risk of hyperkalemia in patients with kidney diseaseYes/noβ-BlockerBisoprololPrevention and treatment of ischemic heart diseaseYesStatinsSimvastatinPrevention of CAD in patients with CKD, tra