Burden, access, and disparities in kidney disease - World Kidney Day

Burden, access, and disparities in kidney disease - World Kidney Day
editorial                                                                                                                     www.kidney-international.org

                                    Burden, access, and disparities in
                                    kidney disease
                                    Kidney International (2019) 95, 242–248; https://doi.org/10.1016/j.kint.2018.11.007
                                    KEYWORDS: acute kidney injury; end stage renal disease; global health; health equity; social determinants of health
                                    ª World Kidney Day 2019 Steering Committee

                                           idney disease is a global public health                 quite variable across settings. This situation is of

Deidra C. Crews ,  1,2,3
                                    K      problem that affects more than 750
                                           million persons worldwide.1 The burden
                                    of kidney disease varies substantially across the
                                                                                                   particular concern in low-income countries. For
                                                                                                   example, a meta-analysis of 90 studies on CKD
                                                                                                   burden conducted across Africa showed very few
Aminu K. Bello4 and                 world, as does its detection and treatment.                    studies (only 3%) with robust data.5 The provi-
Gamal Saadi5; for the               Although the magnitude and impact of kidney                    sion of adequate resources and a workforce to
World Kidney Day Steering           disease is better defined in developed countries,               establish and maintain surveillance systems (e.g.,
Committee6                          emerging evidence suggests that developing                     screening programs and registries) is essential
                                                                                                   and requires substantial investment.6 Incorpo-
 Division of Nephrology,            countries have a similar or even greater kidney
Department of Medicine, Johns       disease burden.2                                               rating kidney disease surveillance parameters in
Hopkins University School of
Medicine, Baltimore, Maryland,
                                       In many settings, rates of kidney disease and               existing chronic disease prevention programs
USA; 2Welch Center for              the provision of its care are defined by socio-                 might enhance global efforts toward obtaining
Prevention, Epidemiology and        economic, cultural, and political factors, lead-               high-quality information on kidney disease
Clinical Research, Johns            ing to significant disparities in disease burden,               burden and attendant consequences.
Hopkins Medical Institutions,       even in developed countries.3 These disparities
Baltimore, Maryland, USA;
                                                                                                       In addition to a need for functional sur-
 Johns Hopkins Center for
                                    exist across the spectrum of kidney disease—                   veillance systems, the global importance of
Health Equity, Johns Hopkins        from preventive efforts to curb development of                 kidney disease (including AKI and CKD) is yet
Medical Institutions, Baltimore,    acute kidney injury (AKI) or chronic kidney                    to be widely acknowledged, making it a
Maryland, USA; 4Division of         disease (CKD), to screening for kidney disease                 neglected disease on the global policy agenda.
Nephrology & Transplant             among persons at high risk, to access to sub-
Immunology, Department of
                                                                                                   For instance, the World Health Organization
Medicine, University of Alberta,
                                    specialty care and treatment of kidney failure                 (WHO) Global Action Plan for the Prevention
Edmonton, Canada; and               with renal replacement therapy (RRT). World                    and Control of Non-Communicable Diseases
 Nephrology Unit, Department        Kidney Day 2019 offers an opportunity to raise                 (NCDs) (2013) focuses on cardiovascular dis-
of Internal Medicine, Faculty of    awareness of kidney disease and highlight dis-                 eases, cancer, chronic respiratory diseases, and
Medicine, Cairo University, Giza,   parities in its burden and current state of global
                                                                                                   diabetes but not kidney disease, despite advo-
                                    capacity for prevention and management. In                     cacy efforts by relevant stakeholders such as the
Correspondence: Deidra C.
                                    this editorial, we highlight these disparities and             International Society of Nephrology and the
Crews, Johns Hopkins University
School of Medicine, 301 Mason       emphasize the role of public policies and                      International Federation of Kidney Founda-
F. Lord Drive, Suite 2500,          organizational structures in addressing them.                  tions through activities such as World Kidney
Baltimore, Maryland 21224,          We outline opportunities to improve our un-                    Day. This situation is quite concerning because
USA. E-mail: dcrews1@jhmi.edu       derstanding of disparities in kidney disease, the              estimates from the Global Burden of Disease
This article is being published     best ways for them to be addressed, and how to                 study in 2015 showed that around 1.2 million
in Kidney International and         streamline efforts toward achieving kidney                     people were known to have died of CKD,7 and
reprinted concurrently in
                                    health equity across the globe.                                more than 2 million people died in 2010
several journals. The articles
cover identical concepts and                                                                       because they had no access to dialysis. It is
                                    Burden of kidney disease
wording, but vary in minor                                                                         estimated that another 1.7 million die from
                                    Availability of data reflecting the full burden of
stylistic and spelling changes,                                                                    AKI on an annual basis.8,9 It is possible,
detail, and length of manu-         kidney disease varies substantially because of
                                                                                                   therefore, that kidney disease may contribute to
script in keeping with each         limited or inconsistent data collection and sur-
                                                                                                   more deaths than the 4 main NCDs targeted by
journal’s style. Any of these       veillance practices worldwide (Table 1).4
versions may be used in citing                                                                     the current NCD Action Plan.
                                    Whereas several countries have national data
this article.
                                    collection systems, particularly for end-stage                    Risk factors for kidney disease. Data in
Note that all authors contrib-                                                                     recent decades have linked a host of genetic,
                                    renal disease (ESRD) (e.g., United States Renal
uted equally to the concep-
tion, preparation, and editing      Data System, Latin American Dialysis and Renal                 environmental, sociodemographic, and clinical
of the manuscript.                  Transplant Registry, and Australia and New                     factors to risk of kidney disease. The popula-
 See Appendix for list of
                                    Zealand Dialysis and Transplant Registry), high-               tion burden of kidney disease is known to
members of the World Kidney         quality data regarding nondialysis CKD is                      correlate with socially defined factors in most
Day Steering Committee.             limited, and often the quality of ESRD data is                 societies across the world. This phenomenon is

242                                                                                                                       Kidney International (2019) 95, 242–248
Burden, access, and disparities in kidney disease - World Kidney Day

                                          Table 1 | World Bank country group chronic kidney disease gaps
                                                                                 Low-income     Lower-middle-income   Upper middle-income    High-income
                                          CKD care                              countries (%)      countries (%)         countries (%)       countries (%)

                                          Governmental recognition of                59                 50                     17                 29
                                            CKD as a health priority
                                          Government funds all aspects of            13                 21                     40                 53
                                            CKD care
                                          Availability of CKD management             46                 73                     83                 97
                                            and referral guidelines
                                            (international, national, or
                                          Existence of current CKD                    6                 24                     24                 32
                                            detection programs
                                          Availability of dialysis registries        24                 48                     72                 89
                                          Availability of academic centers           12                 34                     62                 63
                                            for renal clinical trial
                                          CKD, chronic kidney disease.
                                          Data from Bello et al.4

                                          better documented in high-income countries,                  are limited. Hypertension is also estimated to
                                          where racial/ethnic minority groups and people               affect 1 billion persons worldwide20 and is the
                                          of low socioeconomic status carry a high burden              second leading attributed cause of CKD.18
                                          of disease. Extensive data have demonstrated that            Hypertension control is important for slowing
                                          racial and ethnic minorities (e.g., African                  CKD progression and decreasing mortality risk
                                          Americans in the United States, Aboriginal                   among persons with or without CKD. Hyper-
                                          groups in Canada and Australia, Indo-Asians in               tension is present in more than 90% of persons
                                          the United Kingdom, and others) are affected                 with advanced kidney disease,18 yet racial/
                                          disproportionately by advanced and progressive               ethnic minorities and low-income persons with
                                          kidney disease.10–12 The associations of socio-              CKD who live in high-income countries have
                                          economic status and risk of progressive CKD and              poorer blood pressure control than their more
                                          eventual kidney failure also have been well                  socially advantaged counterparts.21
                                          described, with persons of lower socioeconomic                  Lifestyle behaviors, including dietary pat-
                                          status bearing the greatest burden.13,14                     terns, are strongly influenced by socioeconomic
                                              Recent works have associated apolipopro-                 status. In recent years, several healthful dietary
                                          tein L1 risk variants15,16 with increased kidney             patterns have been associated with favorable
                                          disease burden among persons with African                    CKD outcomes.22 Low-income persons often
                                          ancestry. In Central America and South-                      face barriers to healthful eating that may in-
                                          eastern Mexico, Mesoamerican nephropathy                     crease their risk of kidney disease.23–25 People
                                          (also referred to as CKD of unknown causes)                  of low socioeconomic status often experience
                                          has emerged as an important cause of kidney                  food insecurity (i.e., limited access to affordable
                                          disease. While multiple exposures have been                  nutritious foods), which is a risk factor for
                                          studied for their potential role in CKD of                   CKD26 and progression to kidney failure.27 In
                                          unknown causes, recurrent dehydration and                    low-income countries, food insecurity may lead
                                          heat stress are common denominators in most                  to undernutrition and starvation, which has
                                          cases.17 Other perhaps more readily modifi-                   implications for the individual and, in the case
                                          able risk factors for kidney disease and CKD                 of women of child-bearing age, could lead to
                                          progression that disproportionately affect so-               their children having low birth weight and
                                          cially disadvantaged groups also have been                   related sequelae, including CKD.28 Rates of
                                          identified, including disparate rates and poor                undernourishment are as high as 35% or more
                                          control of clinical risk factors such as diabetes            in countries such as Haiti, Namibia, and
                                          and hypertension, as well as lifestyle                       Zambia.29 However, in high-income countries,
                                          behaviors.                                                   food insecurity is associated with overnutrition,
                                              Diabetes is the leading cause of advanced                and persons with food insecurity have
                                          kidney disease worldwide.18 In 2016, 1 in 11                 increased risk of overweight and obesity.30,31
                                          adults worldwide had diabetes and more than                  Further, food insecurity has been associated
                                          80% were living in low- and middle-income                    with several diet-related conditions, including
                                          countries19 where resources for optimal care                 diabetes and hypertension.

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                Acute kidney injury. AKI is an underdetected       that patients and families were burdened with
            condition that is estimated to occur in 8% to 16%      having to navigate multiple health and social
            of hospital admissions32 and is now well estab-        care structures, negotiate treatments and costs,
            lished as a risk factor for CKD.33 Disparities in      finance their health care, and manage health
            AKI risk are also common, following a pattern          information.40 Challenges may be even greater
            similar to that observed in persons with CKD.34        for families of children with ESRD, because
            AKI related to nephrotoxins, alternative (tradi-       many regions lack qualified pediatric care
            tional) medicines, infectious agents, and hospi-       centers.
            talizations and related procedures are more
            pronounced in low-income and lower-middle-             Organization and structures for kidney disease
            income countries and contribute to increased           care
            risk of mortality and CKD in those settings.35         The lack of recognition and therefore the
            Importantly, the majority of annual AKI cases          absence of a global action plan for kidney dis-
            worldwide (85% of more than 13 million cases)          ease partly explains the substantial variation in
            are experienced in low-income and lower-middle-        structures and capacity for kidney care around
            income countries, leading to 1.4 million deaths.36     the globe. This situation has resulted in varia-
                                                                   tions in government priorities, health care
            Health policies and financing of kidney disease         budgets, care structures, and human resource
            care                                                   availability.41 Effective and sustainable advo-
            Because of the complex and costly nature of            cacy efforts are needed at global, regional, and
            kidney disease care, its provision is tightly linked   national levels to get kidney disease recognized
            with the public policies and financial status of        and placed on the global policy agenda.
            individual countries. For example, gross domes-            In 2017, the International Society of
            tic product is correlated with lower dialysis-to-      Nephrology collected data on country-level ca-
            transplantation ratios, suggesting greater rates       pacity for kidney care delivery using a survey, the
            of kidney transplantation in more financially           Global Kidney Health Atlas,4 which aligned with
            solvent nations. In several high-income coun-          the WHO’s building blocks of a health system.
            tries, universal health care is provided by the        The Global Kidney Health Atlas highlights limited
            government and includes CKD and ESRD care.             awareness of kidney disease and its consequences
            In other countries, such as the United States,         and persistent inequities in resources required to
            ESRD care is publicly financed for citizens;            tackle the burden of kidney disease across the
            however, optimal treatment of CKD and its risk         globe. For example, CKD was recognized as a
            factors may not be accessible for persons lacking      health care priority by government in only 36% of
            health insurance, and regular care of undocu-          countries that participated in this survey. The
            mented immigrants with kidney disease is not           priority was inversely related to income level:
            covered.37 In low-income and lower-middle-             CKD was a health care priority in more than half
            income countries, neither CKD nor ESRD care            of low-income and lower-middle-income coun-
            may be publicly financed, and CKD prevention            tries but in less than 30% of upper-middle-
            efforts are often limited. In several such coun-       income and high-income countries.
            tries, collaborations between public and private           Regarding capacity and resources for kidney
            sectors have emerged to provide funding for RRT.       care, many countries still lack access to basic di-
            For example, in Karachi, Pakistan, a program of        agnostics, a trained nephrology workforce, uni-
            dialysis and kidney transplantation through joint      versal access to primary health care, and RRT
            community and government funding has existed           technologies. Low-income and lower-middle-
            for more than 25 years.38                              income countries, especially in Africa, had
                In many settings, persons with advanced            limited services for the diagnosis, management,
            CKD who have no or limited public or private           and monitoring of CKD at the primary care level,
            sector funding for care shoulder a substantial         with only 12% having serum creatinine mea-
            financial burden. A systematic review of 260            surement, including estimated glomerular filtra-
            studies including patients from 30 countries           tion rate. Twenty-nine percent of low-income
            identified significant challenges, including             countries had access to qualitative urinalysis using
            fragmented care of indeterminate duration,             urine test strips; however, no low-income country
            reliance on emergency care, and fear of cata-          had access to urine albumin-to-creatinine ratio or
            strophic life events because of diminished             urine protein-to-creatinine ratio measurements at
            financial capacity to withstand them.39 Authors         the primary care level. Across all world countries,
            of another study conducted in Mexico found             availability of services at the secondary/tertiary

244                                                                                    Kidney International (2019) 95, 242–248

                                          care level was considerably higher than at the          low-income regions. For instance, more than
                                          primary care level (Figure 1a and b).4,42               90% of upper-middle-income and high-
                                             Renal replacement therapies. The distribu-           income countries reported having chronic
                                          tion of RRT technologies varied widely. On the          peritoneal dialysis services, whereas these ser-
                                          surface, all countries reported having long-term        vices were available in 64% and 35% of low-
                                          hemodialysis services, and more than 90% of             income and lower-middle-income countries,
                                          countries reported having short-term hemodi-            respectively. In comparison, acute peritoneal
                                          alysis services. However, access to and distri-         dialysis had the lowest availability across all
                                          bution of RRT across countries and regions was          countries. More than 90% of upper-middle-
                                          highly inequitable, often requiring prohibitive         income and high-income countries reported
                                          out-of-pocket expenditure, particularly in              having kidney transplant services, with more

Figure 1 | Health care services for identification and management of chronic kidney disease by country income level. (a) Primary care (i.e.,
basic health facilities at community levels [e.g., clinics, dispensaries, and small local hospitals]). (b) Secondary/specialty care (i.e., health facilities
at a level higher than primary care [e.g., clinics, hospitals, and academic centers]). eGFR, estimated glomerular filtration rate; HbA1C, glycated
hemoglobin; UACR, urine albumin-to-creatinine ratio; UPCR, urine protein-to-creatinine ratio. Data from Bello et al.4 and Htay et al.42

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            than 85% of these countries reporting both                   The appropriate number of nephrologists in
            living and deceased donors as the organ source.          a country depends on many factors, including
            As expected, low-income countries had the                need, priority, and resources, and as such there
            lowest availability of kidney transplant services,       is no global standard with respect to nephrol-
            with only 12% reporting availability, and live           ogist density. Regardless, the demonstrated low
            donors as the only source.                               density in low-income countries calls for
                Workforce for kidney care. Considerable              concern as nephrologists are essential to pro-
            international variation was also noted in the            vide leadership in kidney disease care, and a
            distribution of the kidney care workforce,               lack of nephrologists may result in adverse
            particularly nephrologists. The lowest density           consequences for policy and practice. However,
            (15 nephrologists           low-income and lower-middle-income coun-
            per million population) was reported mainly in           tries, in part thanks to fellowship programs
            high-income countries (Figure 2).4,43,44 Most            supported by international nephrology organi-
            countries reported nephrologists as primarily            zations.45 It is important to note that the role of
            responsible for both CKD and AKI care. Pri-              a nephrologist may differ depending on how
            mary care physicians had more responsibility             the health care system is structured. The den-
            for CKD care than for AKI care, as 64% of                sity statistic merely represents the number of
            countries reported that primary care physicians          nephrologists per million population and pro-
            are primarily responsible for CKD care and               vides no indication of the adequacy to meet the
            35% reported that they are responsible for AKI           needs of the population or quality of care,
            care. Intensive care specialists were primarily          which depends on volume of patients with
            responsible for AKI in 75% of countries, likely          kidney disease and other workforce support
            because AKI is typically treated in hospitals.           (e.g., availability of multidisciplinary teams).
            However, only 45% of low-income countries                    For other care providers essential for kidney
            reported that intensive care specialists were            care, international variations exist in distribution
            primarily responsible for AKI, compared with             (availability and adequacy). Overall, provider
            90% of high-income countries; this discrepancy           shortages were highest for renal pathologists,
            may be due to a general shortage of intensive            vascular access coordinators, and dietitians (with
            care specialists in low-income countries.                86%, 81%, and 78% of countries reporting a

            Figure 2 | Nephrologist availability (density per million population) compared with physician, nursing, and
            pharmaceutical personnel availability by country income level. Pharmaceutical personnel include pharmacists,
            pharmaceutical assistants, and pharmaceutical technicians. Nursing and midwifery personnel include
            professional nurses, professional midwives, auxiliary nurses, auxiliary midwives, enrolled nurses, enrolled
            midwives, and related occupations such as dental nurses. A logarithmic scale was used for the x-axis [log(xþ1)]
            because of the large range in provider density. Data from Bello et al.,4 Osman et al.,43 and the World Health
            Organization (for pharmaceutical personnel: http://apps.who.int/gho/data/view.main.PHARMS and http://apps.
            who.int/gho/data/node.main-amro.HWF?lang¼en, for nursing and midwifery personnel: http://apps.who.int/
            gho/data/view.main.NURSES, for physicians: http://apps.who.int/gho/data/view.main.92000).44

246                                                                                       Kidney International (2019) 95, 242–248

                                          shortage, respectively), and the shortages were          worldwide. The provision and delivery of kid-
                                          more common in low-income countries. Few                 ney care varies widely across the world.
                                          countries (35%) reported a shortage in laboratory        Achieving universal health coverage worldwide
                                          technicians. This information highlights signifi-         by 2030 is one of the WHO Sustainable
                                          cant inter- and intra-regional variability in the        Development Goals. Although universal health
                                          current capacity for kidney care across the world.       coverage may not include all elements of kidney
                                          Important gaps in awareness, services, workforce,        care in all countries (because this is usually a
                                          and capacity for optimal care delivery were iden-        function of political, economic, and cultural
                                          tified in many countries and regions.4 The find-           factors), understanding what is feasible and
                                          ings have implications for policy development            important for a country or region with a focus
                                          with regard to establishment of robust kidney care       on reducing the burden and consequences of
                                          programs, particularly for low-income and lower-         kidney disease would be an important step
                                          middle-income countries.46 The Global Kidney             toward achieving kidney health equity.
                                          Health Atlas has therefore provided a baseline
                                          understanding of where countries and regions
                                          stand with respect to several domains of the health      Members of the World Kidney Day Steering Committee are Philip
                                          system, thus allowing the monitoring of progress         Kam Tao Li, Guillermo Garcia-Garcia, Sharon Andreoli, Deidra
                                          through the implementation of various strategies         Crews, Kamyar Kalantar-Zadeh, Charles Kernahan, Latha Kumar-
                                                                                                   aswami, Gamal Saadi, and Luisa Strani.
                                          aimed at achieving equitable and quality care for
                                          the many patients with kidney disease across the         DISCLOSURE
                                          globe.                                                   All the authors declared no competing interests.
                                              How could this information be used to miti-
                                          gate existing barriers to kidney care? First, basic      The authors thank the Global Kidney Health Atlas
                                          infrastructure for services must be strengthened         Team, M. Lunney, and M.A. Osman.
                                          at the primary care level for early detection and
                                          management of AKI and CKD across all coun-               REFERENCES
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