In the JournalsPerspective

Significant gaps in kidney disease care worldwide

There are vast interregional and intraregional differences in kidney care around the world, with significant gaps in care in both developed and developing countries, according to research recently published in JAMA.

According to the researchers, the U.S. has a 14% prevalence rate of chronic kidney disease. Worldwide, one in three people in the general population is at increased risk for the disease. Although an estimated 10% of people have kidney disease, an assessment suggests nine in 10 of those affected are unaware of their condition.

“People in the earlier stages of [chronic kidney disease] can be treated with blood pressure-lowering drugs, diet and lifestyle, and can maintain a good quality of life,” Adeera Levin, MD, FRCPC, president of the International Society of Nephrology and professor of medicine at University of British Columbia in Vancouver, Canada, said in a press release. “However, our [report] shows that, across countries of all incomes, many governments are not making kidney disease a priority. This makes no sense, as the costs for treating people with end-stage kidney disease are enormous, along with the devastating effect it has on patients and their families. It is vital therefore that all countries improve their rates of early diagnosis and treatment.”

A team led by Aminu K. Bello, PhD, of the department of medicine at University of Alberta in Edmonton, Canada sent a questionnaire to patient organizations, policy makers, and nephrology societies of 130 countries. Responses were received from 125 countries.

Researchers reported that the United States, Australia, Canada and New Zealand are among the high-income countries where chronic kidney disease is considered low priority, despite having the highest costs for transplantation and dialysis. Conversely, low-income countries such as Burkina Faso, Ethiopia and Nepal recognized chronic kidney disease as a priority, despite their poverty and poor health care systems. Lack of awareness of chronic kidney disease among primary care physicians was highlighted as a major problem, even in high-income countries, where two-thirds of primary care physicians were rated as having extremely low (8%) or low/below average (58%) awareness of the condition.

In addition, 95% of those who responded to the survey worldwide had facilities for hemodialysis,76% had facilities for peritoneal dialysis, and 75% had kidney transplantation facilities. In Africa, of the 35 countries responding, 94% had facilities for hemodialysis, 45% had facilities for peritoneal dialysis and 34% had facilities for kidney transplantation.

The number of nephrologists ranged from more than 15 per 1 million in the U.S. to fewer than 5 per 1 million in parts of Africa, Asia and Latin America.

Renal registry availability was limited, particularly for acute kidney injury (eight countries) and nondialysis chronic kidney disease (nine countries). International acute kidney injury guidelines were accessible in 52 countries, while chronic kidney disease guidelines were accessible in 62 countries.

Bello and colleagues also found that for chronic kidney disease monitoring in primary care, serum creatinine with estimated glomerular filtration rate was always available in 21 countries and proteinuria measurements were always available in nine countries. Hemodialysis was publicly funded and free at the point of care in 50 countries, as was peritoneal dialysis in 48 countries and transplantation services in 46 countries.

“This survey demonstrated significant interregional and intraregional variability in the current capacity for kidney care across the world, including important gaps in servicesand workforce,” Bello and colleagues wrote. “Assuming the responses accurately reflect the status of kidney care in the respondent countries, these findings may be useful to inform efforts to improve the quality of kidney care worldwide.”

In a related editorial, Sreedhar Mandayam, MD, MPH, and Wolfgang C. Winkelmayer, MD, MPH, ScD, both of the Baylor College of Medicine, encouraged stakeholders to put the findings to good use, and start a conversation before the worldwide chronic kidney disease situation becomes bleaker.

“The findings are powerful in setting the stage for a truly global and systematic effort toward addressing kidney diseases and improving disparities in kidney health care. Such an effort is timely in light of the population growth, demographic shifts, and increase in the prevalence of [chronic kidney disease] risk factors (diabetes, hypertension, and obesity) that have contributed to kidney disease nearing the top of the list of the noncommunicable disease burden,” they wrote. “As such, this report mandates a resounding opportunity to join forces globally, regionally, and locally toward improving kidney health now rather than waiting until kidney diseases become one of the top 10 global causes of death, a potential development that is quite foreseeable.”

Bello and colleagues’ findings will be presented at the World Congress of Nephrology in Mexico City, which began today. – by Janel Miller

Disclosures: Neither Bello, Levin nor Mandayam report any relevant financial disclosures. Please see the study and editorial for a full list of the authors’ relevant disclosures.

There are vast interregional and intraregional differences in kidney care around the world, with significant gaps in care in both developed and developing countries, according to research recently published in JAMA.

According to the researchers, the U.S. has a 14% prevalence rate of chronic kidney disease. Worldwide, one in three people in the general population is at increased risk for the disease. Although an estimated 10% of people have kidney disease, an assessment suggests nine in 10 of those affected are unaware of their condition.

“People in the earlier stages of [chronic kidney disease] can be treated with blood pressure-lowering drugs, diet and lifestyle, and can maintain a good quality of life,” Adeera Levin, MD, FRCPC, president of the International Society of Nephrology and professor of medicine at University of British Columbia in Vancouver, Canada, said in a press release. “However, our [report] shows that, across countries of all incomes, many governments are not making kidney disease a priority. This makes no sense, as the costs for treating people with end-stage kidney disease are enormous, along with the devastating effect it has on patients and their families. It is vital therefore that all countries improve their rates of early diagnosis and treatment.”

A team led by Aminu K. Bello, PhD, of the department of medicine at University of Alberta in Edmonton, Canada sent a questionnaire to patient organizations, policy makers, and nephrology societies of 130 countries. Responses were received from 125 countries.

Researchers reported that the United States, Australia, Canada and New Zealand are among the high-income countries where chronic kidney disease is considered low priority, despite having the highest costs for transplantation and dialysis. Conversely, low-income countries such as Burkina Faso, Ethiopia and Nepal recognized chronic kidney disease as a priority, despite their poverty and poor health care systems. Lack of awareness of chronic kidney disease among primary care physicians was highlighted as a major problem, even in high-income countries, where two-thirds of primary care physicians were rated as having extremely low (8%) or low/below average (58%) awareness of the condition.

In addition, 95% of those who responded to the survey worldwide had facilities for hemodialysis,76% had facilities for peritoneal dialysis, and 75% had kidney transplantation facilities. In Africa, of the 35 countries responding, 94% had facilities for hemodialysis, 45% had facilities for peritoneal dialysis and 34% had facilities for kidney transplantation.

The number of nephrologists ranged from more than 15 per 1 million in the U.S. to fewer than 5 per 1 million in parts of Africa, Asia and Latin America.

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Renal registry availability was limited, particularly for acute kidney injury (eight countries) and nondialysis chronic kidney disease (nine countries). International acute kidney injury guidelines were accessible in 52 countries, while chronic kidney disease guidelines were accessible in 62 countries.

Bello and colleagues also found that for chronic kidney disease monitoring in primary care, serum creatinine with estimated glomerular filtration rate was always available in 21 countries and proteinuria measurements were always available in nine countries. Hemodialysis was publicly funded and free at the point of care in 50 countries, as was peritoneal dialysis in 48 countries and transplantation services in 46 countries.

“This survey demonstrated significant interregional and intraregional variability in the current capacity for kidney care across the world, including important gaps in servicesand workforce,” Bello and colleagues wrote. “Assuming the responses accurately reflect the status of kidney care in the respondent countries, these findings may be useful to inform efforts to improve the quality of kidney care worldwide.”

In a related editorial, Sreedhar Mandayam, MD, MPH, and Wolfgang C. Winkelmayer, MD, MPH, ScD, both of the Baylor College of Medicine, encouraged stakeholders to put the findings to good use, and start a conversation before the worldwide chronic kidney disease situation becomes bleaker.

“The findings are powerful in setting the stage for a truly global and systematic effort toward addressing kidney diseases and improving disparities in kidney health care. Such an effort is timely in light of the population growth, demographic shifts, and increase in the prevalence of [chronic kidney disease] risk factors (diabetes, hypertension, and obesity) that have contributed to kidney disease nearing the top of the list of the noncommunicable disease burden,” they wrote. “As such, this report mandates a resounding opportunity to join forces globally, regionally, and locally toward improving kidney health now rather than waiting until kidney diseases become one of the top 10 global causes of death, a potential development that is quite foreseeable.”

Bello and colleagues’ findings will be presented at the World Congress of Nephrology in Mexico City, which began today. – by Janel Miller

Disclosures: Neither Bello, Levin nor Mandayam report any relevant financial disclosures. Please see the study and editorial for a full list of the authors’ relevant disclosures.

    Perspective
    Josef Coresh

    Josef Coresh

    This is an important report from an initiative by the International Society of Nephrology. This report relies on a survey of mostly nephrologists from most of the countries around the world to summarize the state of kidney related health care globally.

    The advantage of this report is that it provides one of the most comprehensive descriptions of health care for kidney disease globally. The disadvantage is that it is a subjective report by a few health care providers in each country. Overall, Dr. Bello and others find that provisions of care for kidney disease globally is quite variable. This is not unexpected, given that awareness of chronic kidney disease having a high impact on population health is relatively recent and lags the awareness for disease such as heart disease, cancer, diabetes and hypertension.

    Generally, high-income countries had facilities for hemodialysis, peritoneal dialysis, and kidney transplantation whereas lower income countries were less likely to have all of these facilities. In particular, geographically, Africa stands out as an area with lower capacity for kidney health care. In the future it would be useful to quantify the resources within each country beyond yes/no and broad subjective categories.

    The article also points out that automated reporting of estimated glomerular filtration rate significantly lags the ability to test for serum creatinine. This should be quite addressable since moving from serum creatinine to estimated glomerular filtration rate only requires a calculation which can be done by any computer that is available in the laboratory. Therefore, this is an area where information can be improved dramatically with relatively little effort or cost.

    Finally, the number of nephrologists was low in a number of world regions, suggesting there is both a need to train more nephrologists, and to rely on other health care providers in addressing the high and increasing global problem of chronic kidney disease. Overall, kidney disease is increasingly recognized as an important non-communicable disease which deserves greater awareness and a broader partnership across health care delivery organizations to improve diagnosis, care and outcomes.

    • Josef Coresh, MD, PhD
    • professor, departments of epidemiology and biostatistics, Johns Hopkins University, Baltimore, Maryland

    Disclosures: Coresh reports no relevant financial disclosures.

    Perspective
    Jonathan Himmelfarb

    Jonathan Himmelfarb

    The paper “Assessment of Global Kidney Health Status” published in JAMA, reports the results of an international survey conducted by the International Society of Nephrology, assessing the capacity for kidney care throughout the world. Key stakeholders from a total of 125 countries, representing 6.8 billion people (93% of the world’s population responded). This is the first systematic assessment of the capacity of health care systems throughout the world to care for patients with kidney disease. The survey results revealed that there is very large variation in the capacity to provide kidney health services in many regions of the world, with large intra-regional and inter-regional variation. While most countries have capacity to provide at least some dialysis or transplant care, measurement of serum creatinine to assess earlier stages of kidney disease is often not available at the primary care level. There are limited abilities to track kidney disease within populations, and in many countries there is a shortage of available nephrologists to deliver specialty care. These data suggest that relatively large gaps in meeting the need of people who develop kidney disease will be difficult to overcome.

    The data from this important study should be interpreted in context of another recently published study in the Journal of the American Society of Nephrology, entitled: “Global Cardiovascular and Renal Outcomes of Reduced GFR.” This landmark study quantifies for the first time the burden of premature death and health loss from reduced kidney function (chronic kidney disease) for 188 countries. The results are quite striking in demonstrating a high prevalence of kidney disease throughout the world, and also demonstrating the reduced kidney function is associated with 4% of deaths worldwide (approximately 2.2 million deaths) annually. Among people with kidney disease, cardiovascular deaths outnumbered deaths due to irreversible kidney failure.

    These two studies clearly indicate that kidney disease is a major global health problem.

    • Jonathan Himmelfarb, MD
    • professor of medicine, University of Washington and director, Kidney Research Institute

    Disclosures: Himmelfarb reports no relevant financial disclosures.