Global challenges in kidney diseases

Global challenges in kidney diseases Kidney disease as an important global health problem has been increasingly recognized over the last decade. Data collated by the Global Burden of Disease group have demonstrated that chronic kidney disease (CKD) as a cause of years of life lost has risen from 25th in 1990 to 17th in 2015 [1, 2]. Not only are years of life lost, but in addition, disability from kidney disease is growing at a rate of 1.3% per year. Thus, the impacts on patients, families, health care systems and society are profound. Estimates for costs associated with treatment of kidney failure (dialysis or transplantation) are disproportionate to the size of the population in all environments (estimate of 1–2% of health care spending on <0.5% of the population), and costs of diagnosis, prevention and delay of progression have been poorly estimated to date, but given that up to 10% of the adult population have kidney disease, these costs are even higher [3]. Kidney disease is increasingly recognized as a complex heterogeneous set of conditions, which can be acute or chronic. Irrespective of the duration of reduction in kidney function, the consequences to individuals and to populations is devastating. The Global Burden of Disease and the International Society of Nephrology (ISN) Global Kidney Health Atlas (GKHA) offer some insights into the impact of CKD on various populations [2, 4]. The GKHA describes the state of kidney care according to the six dimensions of Universal Health Coverage, using robust survey methodology, and capturing data from 125 countries, representing 93% of the world’s population. The global distribution of nephrologists is described as 8.83 per 1.87 million population, with huge disparities between low-, low middle-, upper middle- and high-income countries. In some locations, no aspect of kidney care is funded, and there are few registries for CKD or acute kidney injury, and despite the enormous cost of dialysis and transplantation, even basic registries for these modalities are not available in all jurisdictions. Basic testing for urine and blood with reliable laboratory systems is not available in all locations. The capacity for conducting longitudinal cohort studies, with biosample banking, or clinical trials is disproportionately available to high-income countries, relative to those in low- and low middle-income countries, despite very large affected populations in those areas [5–7]. The global challenges in improving outcomes for patients living with kidney disease given this current state are profound. The lack of basic testing and services, compounded by a lack of systematically collected information, put the nephrology community in a compromised position with respect to advocacy and advancing the science. Where data do exist, we observe large variations in prevalence, rates of progression and outcomes depending on regions of the world, socioeconomic status, access to care and genetics. There are important hotspots of kidney disease, which suggest important interaction of genes and environment (e.g. Chronic Kidney Disease of undetermined origina) [8]. This variation in access to care, information and registries to document the size of the problem contributes to some of the inability to change outcomes. Our lack of research infrastructure and a culture of inquiry has further limited our progress. The ethical and financial aspects of offering high cost dialysis therapy, or transplant therapy, in regions where basic human needs are not met are further challenges [9]. Nonetheless, with international collaborations, there is an increasing ability to study a variety of conditions, and appreciate the context of multiple gene profiles within multiple environments and with various exposures, at different points in time, so that we do better understand basic biology, and use the important information to target specific molecules and pathways, so that promising therapies can be offered as hope to patients. The large variability in access to care, research and knowledge translation may limit our ability to reap the potential advances offered by increasingly sophisticated tools and methodologies. However, by systematically addressing each issue, as described in the Roadmap publication [10], we hope to close those gaps. Through collaborations, sharing of biosamples, databases, common protocols and multicenter trials conducted worldwide, an improved understanding of diseases affecting populations will be realized. Defining new methods of conducting trials, collecting and storing specimens and sharing data is imperative in order to better understand the kidney diseases in all parts of the world. There are an increasing number of international consortia of networks that include patients, researchers and policymakers in different roles, so that we may begin to address some of the issues limiting our ability to move forward: the International Society of Nephrology is supporting the International Network of CKD cohorts (iNET CKD) advancing clinical trials, as are other institutions such as the George Global Health Clinical Institute, supporting NEPTUNE and C-PROVE (www.theisn.org) (Figure 1). FIGURE 1 View largeDownload slide Achieving better kidney health. FIGURE 1 View largeDownload slide Achieving better kidney health. The issues facing global kidney health suggest a need for infrastructure and knowledge exchange platforms, and access to basic medicines, nutrition and clean water. There are serious challenges, but some exciting opportunities facing the clinical and research kidney communities. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1 Eckardt K-U, Coresh J, Devuyst O et al.   Evolving importance of kidney disease: from subspecialty to global health burden. Lancet  2013; 382: 158– 169 Google Scholar CrossRef Search ADS PubMed  2 GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet  2016; 388: 1459– 1544 CrossRef Search ADS PubMed  3 Wyld ML, Lee CM, Zhuo X et al.   Cost to government and society of chronic kidney disease stage 1-5: a National Cohort Study. Intern Med J  2015; 45: 741– 747 Google Scholar CrossRef Search ADS PubMed  4 Bello AK, Levin A, Tonelli M et al.   Assessment of global kidney health care status. JAMA  2017; 317: 1864– 1881 Google Scholar CrossRef Search ADS PubMed  5 Htay H, Alrukhaimi M, Ashuntantang GE et al.   Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project. Kidney Int Suppl  2018; 8: 64– 73 Google Scholar CrossRef Search ADS   6 See EJ, Alrukhaimi M, Ashuntantang GE et al.   Global coverage of health information systems for kidney disease: availability, challenges, and opportunities for development. Kidney Int Suppl  2018; 8: 74– 81 Google Scholar CrossRef Search ADS   7 Okpechi IG, Alrukhaimi M, Ashuntantang GE et al.   Global capacity for clinical research in nephrology: a survey by the International Society of Nephrology. Kidney Int Suppl  2018; 8: 82– 89 Google Scholar CrossRef Search ADS   8 Weaver VM, Fadrowski JJ, Jaar BG. Global dimensions of chronic kidney disease of unknown etiology (CKDu): a modern era environmental and/or occupational nephropathy? BMC Nephrology  2015; 16: 145 Google Scholar CrossRef Search ADS PubMed  9 Jha V, Martin DE, Bargman JM et al.   Ethical issues in dialysis therapy. Lancet  2017; 389: 1851– 1856 Google Scholar CrossRef Search ADS PubMed  10 Levin A, Tonelli M, Bonventre J et al.   Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy. Lancet  [Online] http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30788-2/abstract (10 January 2018, date last accessed) © The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Nephrology Dialysis Transplantation Oxford University Press

Global challenges in kidney diseases

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Publisher
Oxford University Press
Copyright
© The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
ISSN
0931-0509
eISSN
1460-2385
D.O.I.
10.1093/ndt/gfy037
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Abstract

Kidney disease as an important global health problem has been increasingly recognized over the last decade. Data collated by the Global Burden of Disease group have demonstrated that chronic kidney disease (CKD) as a cause of years of life lost has risen from 25th in 1990 to 17th in 2015 [1, 2]. Not only are years of life lost, but in addition, disability from kidney disease is growing at a rate of 1.3% per year. Thus, the impacts on patients, families, health care systems and society are profound. Estimates for costs associated with treatment of kidney failure (dialysis or transplantation) are disproportionate to the size of the population in all environments (estimate of 1–2% of health care spending on <0.5% of the population), and costs of diagnosis, prevention and delay of progression have been poorly estimated to date, but given that up to 10% of the adult population have kidney disease, these costs are even higher [3]. Kidney disease is increasingly recognized as a complex heterogeneous set of conditions, which can be acute or chronic. Irrespective of the duration of reduction in kidney function, the consequences to individuals and to populations is devastating. The Global Burden of Disease and the International Society of Nephrology (ISN) Global Kidney Health Atlas (GKHA) offer some insights into the impact of CKD on various populations [2, 4]. The GKHA describes the state of kidney care according to the six dimensions of Universal Health Coverage, using robust survey methodology, and capturing data from 125 countries, representing 93% of the world’s population. The global distribution of nephrologists is described as 8.83 per 1.87 million population, with huge disparities between low-, low middle-, upper middle- and high-income countries. In some locations, no aspect of kidney care is funded, and there are few registries for CKD or acute kidney injury, and despite the enormous cost of dialysis and transplantation, even basic registries for these modalities are not available in all jurisdictions. Basic testing for urine and blood with reliable laboratory systems is not available in all locations. The capacity for conducting longitudinal cohort studies, with biosample banking, or clinical trials is disproportionately available to high-income countries, relative to those in low- and low middle-income countries, despite very large affected populations in those areas [5–7]. The global challenges in improving outcomes for patients living with kidney disease given this current state are profound. The lack of basic testing and services, compounded by a lack of systematically collected information, put the nephrology community in a compromised position with respect to advocacy and advancing the science. Where data do exist, we observe large variations in prevalence, rates of progression and outcomes depending on regions of the world, socioeconomic status, access to care and genetics. There are important hotspots of kidney disease, which suggest important interaction of genes and environment (e.g. Chronic Kidney Disease of undetermined origina) [8]. This variation in access to care, information and registries to document the size of the problem contributes to some of the inability to change outcomes. Our lack of research infrastructure and a culture of inquiry has further limited our progress. The ethical and financial aspects of offering high cost dialysis therapy, or transplant therapy, in regions where basic human needs are not met are further challenges [9]. Nonetheless, with international collaborations, there is an increasing ability to study a variety of conditions, and appreciate the context of multiple gene profiles within multiple environments and with various exposures, at different points in time, so that we do better understand basic biology, and use the important information to target specific molecules and pathways, so that promising therapies can be offered as hope to patients. The large variability in access to care, research and knowledge translation may limit our ability to reap the potential advances offered by increasingly sophisticated tools and methodologies. However, by systematically addressing each issue, as described in the Roadmap publication [10], we hope to close those gaps. Through collaborations, sharing of biosamples, databases, common protocols and multicenter trials conducted worldwide, an improved understanding of diseases affecting populations will be realized. Defining new methods of conducting trials, collecting and storing specimens and sharing data is imperative in order to better understand the kidney diseases in all parts of the world. There are an increasing number of international consortia of networks that include patients, researchers and policymakers in different roles, so that we may begin to address some of the issues limiting our ability to move forward: the International Society of Nephrology is supporting the International Network of CKD cohorts (iNET CKD) advancing clinical trials, as are other institutions such as the George Global Health Clinical Institute, supporting NEPTUNE and C-PROVE (www.theisn.org) (Figure 1). FIGURE 1 View largeDownload slide Achieving better kidney health. FIGURE 1 View largeDownload slide Achieving better kidney health. The issues facing global kidney health suggest a need for infrastructure and knowledge exchange platforms, and access to basic medicines, nutrition and clean water. There are serious challenges, but some exciting opportunities facing the clinical and research kidney communities. CONFLICT OF INTEREST STATEMENT None declared. REFERENCES 1 Eckardt K-U, Coresh J, Devuyst O et al.   Evolving importance of kidney disease: from subspecialty to global health burden. Lancet  2013; 382: 158– 169 Google Scholar CrossRef Search ADS PubMed  2 GBD 2015 Mortality and Causes of Death Collaborators. Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980–2015: a systematic analysis for the Global Burden of Disease Study 2015. Lancet  2016; 388: 1459– 1544 CrossRef Search ADS PubMed  3 Wyld ML, Lee CM, Zhuo X et al.   Cost to government and society of chronic kidney disease stage 1-5: a National Cohort Study. Intern Med J  2015; 45: 741– 747 Google Scholar CrossRef Search ADS PubMed  4 Bello AK, Levin A, Tonelli M et al.   Assessment of global kidney health care status. JAMA  2017; 317: 1864– 1881 Google Scholar CrossRef Search ADS PubMed  5 Htay H, Alrukhaimi M, Ashuntantang GE et al.   Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project. Kidney Int Suppl  2018; 8: 64– 73 Google Scholar CrossRef Search ADS   6 See EJ, Alrukhaimi M, Ashuntantang GE et al.   Global coverage of health information systems for kidney disease: availability, challenges, and opportunities for development. Kidney Int Suppl  2018; 8: 74– 81 Google Scholar CrossRef Search ADS   7 Okpechi IG, Alrukhaimi M, Ashuntantang GE et al.   Global capacity for clinical research in nephrology: a survey by the International Society of Nephrology. Kidney Int Suppl  2018; 8: 82– 89 Google Scholar CrossRef Search ADS   8 Weaver VM, Fadrowski JJ, Jaar BG. Global dimensions of chronic kidney disease of unknown etiology (CKDu): a modern era environmental and/or occupational nephropathy? BMC Nephrology  2015; 16: 145 Google Scholar CrossRef Search ADS PubMed  9 Jha V, Martin DE, Bargman JM et al.   Ethical issues in dialysis therapy. Lancet  2017; 389: 1851– 1856 Google Scholar CrossRef Search ADS PubMed  10 Levin A, Tonelli M, Bonventre J et al.   Global kidney health 2017 and beyond: a roadmap for closing gaps in care, research, and policy. Lancet  [Online] http://thelancet.com/journals/lancet/article/PIIS0140-6736(17)30788-2/abstract (10 January 2018, date last accessed) © The Author(s) 2018. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.

Journal

Nephrology Dialysis TransplantationOxford University Press

Published: Mar 1, 2018

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