Mind the gap in kidney care: translating what we know into what we do

Abstract

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 the of some of these may only be in to In the early diagnosis and risk to to or even Tonelli M. 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Annemans L. M. et in kidney health and kidney Rev Nephrol. 2023; Scopus Google Scholar must also the social determinants of health, are of CKD risk and 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 of in kidney health with primary and prevention of kidney disease, Tonelli M. J. et kidney health and a for in and 2017; Full Text Full Text PDF PubMed Scopus Google Scholar of health are to of health and health However, health is to access to kidney V.A. Tonelli M. Stanifer J.W. 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