Chronic kidney disease care models in low- and middle-income countries: a systematic review

Development of a nomogram for predicting depression risk in patients with chronic kidney disease: an analysis of data from the US National Health and Nutrition Examination Survey, 2007-2014

OBJECTIVES

Depression frequently occurs among individuals suffering from chronic kidney disease (CKD), diminishing life quality considerably while accelerating the disease course. This study aims to create a predictive model to identify patients with CKD at high risk for depression.

DESIGN

Analysis of cross-sectional data.

SETTING

US National Health and Nutrition Examination Survey (2007-2014).

PARTICIPANTS

A total of 2303 patients with CKD (weighted=17 422 083) with complete data were included in the analysis.

OUTCOME MEASURES

We used the least absolute shrinkage and selection operator regression for variable selection and constructed a weighted logistic regression model through stepwise backward elimination based on minimisation of the Akaike information criterion, visualised with a nomogram. Internal validation was conducted using 1000 bootstrap resamples. Model discrimination was assessed using receiver operating characteristic curves, calibration was evaluated using the Hosmer-Lemeshow test and calibration curves, and net benefits and clinical impact were analysed using decision curve analysis and comparative impact chart curves.

RESULTS

The final model included 10 predictors: age, gender, poverty income ratio, body mass index, smoking, sleep time, sleep disorder, chest pain, diabetes and arthritis. The model achieved an area under the curve of 0.776 (95% CI 0.745 to 0.806) with good fit (Hosmer-Lemeshow p=0.805). Interventions within the 0.1-0.6 probability range showed significant benefits.

CONCLUSION

We have crafted a predictive model with good discriminative power that could potentially help clinicians identify patients with CKD at high risk for depression, thereby facilitating early intervention and improving the prognosis of these patients.

Chronic kidney disease

Chronic kidney disease (CKD) is defined by persistent abnormalities of kidney function or structure that have consequences for the health. A progressive decline of excretory kidney function has effects on body homeostasis. CKD is tightly associated with accelerated cardiovascular disease and severe infections, and with premature death. Kidney failure without access to kidney replacement therapy is fatal - a reality in many regions of the world. CKD can be the consequence of a single cause, but CKD in adults frequently relates rather to sequential injuries accumulating over the life course or to the presence of concomitant risk factors. The shared pathomechanism of CKD progression is the irreversible loss of kidney cells or nephrons together with haemodynamic and metabolic overload of the remaining nephrons, leading to further loss of kidney cells or nephrons. The management of patients with CKD focuses on early detection and on controlling all modifiable risk factors. This approach includes reducing the overload of the remaining nephrons with inhibitors of the renin-angiotensin system and the sodium-glucose transporter 2, as well as disease-specific drug interventions, if available. Hypertension, anaemia, metabolic acidosis and secondary hyperparathyroidism contribute to cardiovascular morbidity and reduced quality of life, and require diagnosis and treatment.

Exploring the relationship between professional roles and behavioural intentions in chronic kidney disease management: a cross-sectional study among primary and specialist health professionals in Shanghai, China

OBJECTIVES

General practitioners, nephrologists and renal nurses play key roles in professional integration in chronic kidney disease (CKD) management. Professional roles may influence professionals' behavioural intentions, namely, the degree to which individuals formulate behavioural plans to attain a behavioural goal. However, little is known about the relationship between professional roles and their behavioural intentions in CKD management. Therefore, in this study, we aimed to explore the relationship between professional roles and their behavioural intentions in CKD management and the mediating role of normative and functional factors.

DESIGN

Cross-sectional.

SETTING

A cross-sectional survey study was conducted in Shanghai, China.

PARTICIPANTS

A total of 244 responses were obtained, including 145 from general practitioners, 37 from nephrologists and 62 from renal nurses. We used a self-administered questionnaire to collect data through hospital unit/Community Health Service Centre visits. We performed exploratory factor analysis for behavioural intentions in CKD management. The Karlson-Holm-Breen method was used to decompose the total effect of roles on behavioural intentions in CKD management into direct and indirect (ie, mediational) effects and to calculate the mediated percentage.

RESULTS

The indirect effect of personal norm (should CKD management be included in daily work or not) accounted for 51.91% of the total effect of nephrologists on one-to-multiple CKD management intentions and 43.79% of the total effect of renal nurses on one-to-multiple CKD management intentions.

CONCLUSION

Our results support the mediating pathways of personal norms on the relationship between roles and behavioural intentions, but the mediating role of functional factors was not supported. These findings suggest that enhancing the personal norms of general practitioners may benefit their behavioural intentions in CKD management.

Development and validation of interpretable machine learning models to predict glomerular filtration rate in chronic kidney disease Colombian patients

BACKGROUND

ML predictive models have shown their capability to improve risk prediction and assist medical decision-making, nevertheless, there is a lack of accuracy systems to early identify future rapid CKD progressors in Colombia and even in South America.

OBJECTIVE

The purpose of this study was to develop a series of interpretable machine learning models that predict GFR at 6-months, 9-months, and 12-months.

STUDY DESIGN AND SETTING

Over 29,000 CKD patients stage 1 to 3b (estimated GFR, <60 mL/min/1.73 m2) with an average of 3-year follow-up data were included. We used the machine learning extreme gradient boosting (XGBoost) to build three models to predict the next eGFR. Models were internally and externally validated. In addition, we included SHapley Additive exPlanation (SHAP) values to offer interpretable global and local prediction models.

RESULTS

All models showed a good performance in development and external validation. However, the 6-months XGBoost prediction model showed the best performance in internal (MAE average = 6.07; RSME = 78.87), and in external validation (MAE average = 6.45, RSME = 18.94). The top 3 most influential features that pushed the predicted eGFR value to lower values were the interpolated values for eGFR and creatinine, and eGFR at baseline.

CONCLUSION

In the current study we have developed and validated machine learning models to predict the next eGFR value at different intervals. Furthermore, we attempted to approach the need for prediction explanation by offering transparent predictions.

HIV and CKD in the Tenofovir Era: A Prospective Parallel-Group Cohort Study From Tanzania

Rationale & Objective

Longitudinal research on chronic kidney disease (CKD) in sub-Saharan Africa is sparse, especially among people living with HIV (PLWH). We evaluated the incidence of CKD among PLWH compared with HIV-uninfected controls in Tanzania.

Study Design

Prospective cohort study.

Setting & Participants

A total of 495 newly diagnosed PLWH who initiated antiretroviral therapy (ART) and 505 HIV-uninfected adults enrolled from public HIV clinics and followed from 2016-2021. The control group was recruited from HIV treatment partners from the same HIV clinics.

Exposures

Untreated HIV (at baseline), ART, sociodemographic information, health behaviors, hypertension, and diabetes.

Outcomes

Incident CKD, defined as a follow-up estimated glomerular filtration rate (eGFR) of <60 mL/min/1.73 m2 with ≥25% reduction from baseline; annual eGFR change; incident albuminuria; 3-year all-cause mortality.

Analytical Approach

Multivariable Poisson and linear regression determined the association between HIV and other factors with a baseline prevalent reduced eGFR and albuminuria, incident CKD and albuminuria, and annual eGFR change. Cox hazard regression assessed the association between baseline CKD and mortality.

Results

Median age was 35 years and 67.5% were women. There were 101 incident CKD cases, 71 among PLWH and 30 among HIV-uninfected participants, equivalent to a CKD incidence of 57.9 per 1,000 person-years (95% CI, 44.4-71.4) and 26.2 per 1,000 person-years (95% CI, 16.8-35.5), respectively. PLWH had a more rapid eGFR decline (-6.65 vs -2.61 mL/min/1.73 m2 per year). Female sex and older age were positively associated with incident CKD. Albuminuria incidence did not differ by HIV status. PLWH with albuminuria at baseline had higher mortality (HR, 2.13; 95% CI, 1.08-4.21).

Limitations

As an observational cohort study, there was no comparison group of HIV-positive participants on a nontenofovir disoproxil fumarate-based ART regimen.

Conclusions

PLWH receiving tenofovir disoproxil fumarate-based ART had a very high incidence of CKD and rapid eGFR decline. Conversely, albuminuria stabilized with ART use. Expanding access to less-nephrotoxic ART, such as tenofovir alafenamide, is urgently needed throughout sub-Saharan Africa.

Key Performance Indicators of Secondary Health Care in Chronic Kidney Disease: Experience in Public and Private Services in the State of São Paulo, Brazil

Introduction: The objective of this study was to evaluate quality indicators of secondary health care in chronic kidney disease (CKD). Methods: This retrospective longitudinal study was conducted in an outpatient medical nephrology clinic of the Brazilian Unified Health System (UHS) and a multidisciplinary outpatient clinic of a private health plan (PHP). The inclusion criteria were age ≥ 18 years, ≥ 3 medical appointments, and follow-up time ≥ 6 months. Results: Compared to PHP patients (n = 183), UHS patients (n = 276) were older (63.4 vs. 59.7 years, p=0.04), had more arterial hypertension (AH) (91.7% vs. 84.7%, p=0.02) and dyslipidemia (58.3 vs. 38.3%, p < 0.01), and had a lower estimated baseline glomerular filtration rate (eGFR) (29.9 [21.5-42.0] vs. 39.1 [28.6-54.8] mL/min/1.73 m2, p < 0.01). Compared to PHP patients, UHS patients had a lower percentage of diabetics with glycated hemoglobin < 7.5% (46.1% vs. 61.2%, p=0.03), fewer people with potassium < 5.5 mEq/L (90.4% vs. 95.6%, p=0.04), and fewer referrals for hemodialysis with functioning arteriovenous fistula (AVF) (9.1% vs. 54.3%, p < 0.01). The percentages of people with hypertension and blood pressure < 140 × 90 mmHg were similar between the UHS and PHP groups (59.7% vs. 66.7%; p=0.17), as was the percentage of people with parathyroid hormone control (85.6% vs. 84.8%; p=0.83), dyslipidemia and LDL-cholesterol < 100 mg/dL (38.3% vs. 49.3%; p=0.13), phosphorus < 4.5 mg/dL (78.5% vs. 72.0%; p=0.16), and 25-OH-vitamin-D > 30 ng/mL (28.4% vs. 36.5%; p=0.11). The crude reduction in eGFR was greater in the UHS group than in PHP (2.3 [-0.1; 5.9] vs. 1.1 [-1.9; 4.6] mL/min/1.73 m2; p < 0.01). In the multivariate linear mixed-effects model, UHS patients also showed faster CKD progression over time than PHS ones (group effect, p < 0.01; time effect, p < 0.01; interaction, p < 0.01). Conclusions: Quality of care for patients with CKD can be improved through both services, and multidisciplinary care may have a positive impact on the control of comorbidities, the progression of CKD, and the planning of the initiation of hemodialysis.

A conceptual framework to improve the quality of life in patients with CKD on dialysis in KwaZulu Natal Province, South Africa

Chronic kidney disease (CKD) is one non-communicable disease mainly caused by comorbid of diabetes and hypertension, thus compromising quality of life for the patients. Few rigorous Quality of Life frameworks on chronic kidney disease (CKD) have been reported in low-middle income countries including South Africa. Therefore, the study aimed at developing a Conceptual Framework to improve the Quality of Life in Patients with CKD on Dialysis in KwaZulu Natal Province, South Africa. A Mixed method sequential explanatory design which entails collection of quantitative data, followed by qualitative. A purposive sampling of 316 CKD patients for quantitative was initially selected. For qualitative, 17 healthcare professionals were theoretically sampled until data saturation. A structured questionnaire (WHO HRQOL-BREF) was utilized to collect numerical data for quantitative phase, while focus group discussions provided qualitative insights. The quantitative results indicated low quality of life (QoL) in several dimensions: economic (98 %), psychological (95 %), physical (70 %), and social (55 %). Grounded theory analysis of the qualitative data identified key predictors of QoL as the patients' geographic location, accessibility to haemodialysis centres, their ability to adapt and accept the condition, self-management practices, support from family members and caregivers including the presence of well-trained nursing staff. A comprehensive conceptual framework was developed through identifying contextual factors, interventions and outcomes that is expected to improve the QOL. The study recommends the immediate intervention of the policy makers and health care providers in drafting and implementing policies to improve the QOL in patients with CKD.

Preferences for Advance Care Planning in Patients with End-Stage Kidney Disease: A Cross-Sectional Survey among Nephrology Healthcare Providers in a Tertiary Care Center in India

INTRODUCTION

Advance care planning (ACP) is essential in managing patients with end-stage kidney disease (ESKD), yet its integration into clinical practice remains limited, particularly in low- and middle-income countries. This study explores the preferences, attitudes and perceived barriers of nephrology healthcare providers toward ACP for patients with ESKD in a tertiary care center in India.

METHODS

A cross-sectional survey was conducted among nephrology healthcare providers at a tertiary care center in India. The survey, developed from literature reviews and pretested, covered demographics, ACP knowledge and attitudes, current practices, and perceived barriers and facilitators. Data collection occurred from September 2022 to March 2023. Quantitative data were analyzed descriptively, and qualitative data through thematic analysis.

RESULTS

A total of 50 healthcare providers participated. While 36% acknowledged the importance of ACP, only 8% routinely engaged in ACP discussions. Major barriers included inadequate training (22%), lack of awareness about the importance of discussing ACP among stakeholders (20%), cultural barriers (18%), lack of time (14%), and the absence of institutional protocols for discussion on ACP (14%). Additional barriers included instances where families withhold health information from patients due to fear of losing hope (16%) and patient/family discomfort in discussing ACP (12%). Providers expressed a need for structured ACP protocols and educational programs.

CONCLUSION

Despite recognizing its importance, ACP is underutilized in the care of patients with ESKD in India. Addressing the identified barriers through targeted interventions may enhance ACP practices and improve patient outcomes.

Global data monitoring systems and early identification for kidney diseases

BACKGROUND

Data monitoring and surveillance systems are the cornerstone for governance and regulation, planning, and policy development for chronic disease care. Our study aims to evaluate health systems capacity for data monitoring and surveillance for kidney care.

METHODS

We leveraged data from the third iteration of the International Society of Nephrology Global Kidney Health Atlas (ISN-GKHA), an international survey of stakeholders (clinicians, policymakers and patient advocates) from 167 countries conducted between July and September 2022. ISN-GKHA contains data on availability and types of kidney registries, the spectrum of their coverage, as well as data on national policies for kidney disease identification.

RESULTS

Overall, 167 countries responded to the survey, representing 97.4% of the global population. Information systems in forms of registries for dialysis care were available in 63% (n = 102/162) of countries, followed by kidney transplant registries (58%; n = 94/162), and registries for non-dialysis chronic kidney disease (19%; n = 31/162) and acute kidney injury (9%; n = 14/162). Participation in dialysis registries was mandatory in 57% (n = 58) of countries; however, in more than half of countries in Africa (58%; n = 7), Eastern and Central Europe (67%; n = 10), and South Asia (100%; n = 2), participation was voluntary. The least-reported performance measures in dialysis registries were hospitalization (36%; n = 37) and quality of life (24%; n = 24).

CONCLUSIONS

The variability of health information systems and early identification systems for kidney disease across countries and world regions warrants a global framework for prioritizing the development of these systems.

Diagnostic performance of an albuminuria point-of-care test in screening for chronic kidney disease among young people living with HIV in Uganda: a cross-sectional study

OBJECTIVES

The main aim was to determine the diagnostic performance of an albuminuria point-of-care test (POC) for diagnosis of chronic kidney disease among young people living with HIV (YPLHIV) in Uganda.

DESIGN

We conducted a cross-sectional study comparing the diagnostic performance of MicroalbuPHAN (Erba Lachema, Czech Republic), an albuminuria POC test against the laboratory-measured albumin and creatinine as the reference standard.

SETTING

The study was set in seven HIV clinics in Kampala, Uganda that provide antiretroviral therapy to adults and children living with HIV. The study took place from April to August 2023.

PARTICIPANTS

497 YPLHIV aged 10-24 years who were diagnosed with HIV before 10 years of age were randomly selected from the HIV clinics. Pregnant YPLHIV were excluded.

PROCEDURES

Participants provided a spot urine sample that was tested for albumin and creatinine using the POC and in the laboratory and proteinuria using urine dipstick. The sensitivity, specificity, negative and positive predictive values (NPV, PPV) of the POC versus the laboratory test were calculated, and factors associated with having a positive POC test were estimated using logistic regression.

OUTCOME MEASURES

The primary outcome was a diagnosis of albuminuria defined as an albumin creatinine ratio above 30 mg/g.

RESULTS

Of the 497 participants enrolled, 278 (55.9%) were female and 331 (66.8%) were aged 10-17 years. The POC test had a sensitivity of 74.5% (95% CI 70.6% to 78.4%) and specificity of 68.1% (95% CI 63.9% to 72.3%). The PPV was 21.5% (95% CI 17.8% to 25.1%) and the NPV was 95.8% (95% CI 94.0% to 97.6%), with an accuracy of 68.8%. There was strong evidence that a positive POC test was associated with having proteinuria (OR 2.82; 95% CI 1.89 to 4.22, p<0.001); body mass index <19.5 (OR 1.69 95% CI 1.17 to 2.45, p=0.005) and being male (OR 1.48; 95% CI 1.02 to 2.14, p=0.04).

CONCLUSIONS

The albuminuria POC test had low sensitivity and specificity. However, it can be used to exclude kidney disease given its high NPV. It should be validated against the 24-hour urinary excretion rate to further determine its diagnostic performance.

Overview of global healthcare policies for patients with chronic kidney disease: an integrative literature review

INTRODUCTION

Chronic kidney disease is a progressive and irreversible loss of kidney function and considerably affects the lives of patients and their families. Its high incidence necessitates efficient public policies for prevention and treatment. However, policies for chronic kidney disease education and awareness are scarce.

OBJECTIVE

To evaluate global public policies for the prevention and treatment of chronic kidney disease adopted in various regions, aiming to comprehend the differences between various models.

METHODS

This integrative review followed PRISMA recommendations and included papers published between 2016 and 2021 across several databases.

RESULTS

The 44 selected articles were categorized into three themes: structural and financial aspects of the organization of renal healthcare, access to renal healthcare or management of chronic kidney disease, and coping strategies for chronic kidney disease or kidney health. Critical analysis of the papers revealed global neglect of kidney disease in political agendas. Considerable policy variations exist between different countries and regions of the same country. Our research highlighted that free and universal health coverage, especially for the most vulnerable patients, is crucial for accessing treatment owing to the prohibitively high treatment costs.

CONCLUSION

Social, economic, and ethnic inequalities strongly correlate with disease occurrence, primarily affecting minority groups who lack health support, especially for the prevention and treatment of chronic kidney disease.

Role of primary care in enhancing continuity of care for adolescents and young adults with chronic kidney disease undergoing transition to adult health services

The transition from pediatric to adult health care is a vulnerable period for adolescents and young adults (AYA) with chronic conditions as it involves a multitude of changes and challenges while they enter adulthood. The transition to adult care can be particularly challenging for AYA living with chronic kidney disease (CKD) due to the complex care needed for treatment. Continuity of care is crucial for a successful transition to adult health care. The aim of this educational review is to discuss the potential role of primary care providers in the transition from pediatric to adult health services for AYA with CKD and kidney failure treated with dialysis and/or transplant. We address the significance of the medical home model and how it can provide continuity of care for AYA with CKD. Primary care providers can enhance care for AYA with chronic conditions by providing continuity of care, reducing exacerbation of chronic health conditions, providing holistic care, and fostering collaboration with specialists. Despite their vital role, primary care providers face barriers in maintaining this continuity, necessitating further attention and support in this area. By addressing these barriers and encouraging primary care providers to work alongside pediatric and adult nephrologists during the transition to adult health care, there are significant opportunities to improve the care and health outcomes of AYA with CKD.

Executive summary of the KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease: known knowns and known unknowns

The Kidney Disease: Improving Global Outcomes (KDIGO) Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease (CKD) updates the KDIGO 2012 guideline and has been developed with patient partners, clinicians, and researchers around the world, using robust methodology. This update, based on a substantially broader base of evidence than has previously been available, reflects an exciting time in nephrology. New therapies and strategies have been tested in large and diverse populations that help to inform care; however, this guideline is not intended for people receiving dialysis nor those who have a kidney transplant. The document is sensitive to international considerations, CKD across the lifespan, and discusses special considerations in implementation. The scope includes chapters dedicated to the evaluation and risk assessment of people with CKD, management to delay CKD progression and its complications, medication management and drug stewardship in CKD, and optimal models of CKD care. Treatment approaches and actionable guideline recommendations are based on systematic reviews of relevant studies and appraisal of the quality of the evidence and the strength of recommendations which followed the "Grading of Recommendations Assessment, Development, and Evaluation" (GRADE) approach. The limitations of the evidence are discussed. The guideline also provides practice points, which serve to direct clinical care or activities for which a systematic review was not conducted, and it includes useful infographics and describes an important research agenda for the future. It targets a broad audience of people with CKD and their healthcare, while being mindful of implications for policy and payment.

External validation of a minimal-resource model to predict reduced estimated glomerular filtration rate in people with type 2 diabetes without diagnosis of chronic kidney disease in Mexico: a comparison between country-level and regional performance

Background

Patients with type 2 diabetes are at an increased risk of chronic kidney disease (CKD) hence it is recommended that they receive annual CKD screening. The huge burden of diabetes in Mexico and limited screening resource mean that CKD screening is underperformed. Consequently, patients often have a late diagnosis of CKD. A regional minimal-resource model to support risk-tailored CKD screening in patients with type 2 diabetes has been developed and globally validated. However, population heath and care services between countries within a region are expected to differ. The aim of this study was to evaluate the performance of the model within Mexico and compare this with the performance demonstrated within the Americas in the global validation.

Methods

We performed a retrospective observational study with data from primary care (Clinic Specialized in Diabetes Management in Mexico City), tertiary care (Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán) and the Mexican national survey of health and nutrition (ENSANUT-MC 2016). We applied the minimal-resource model across the datasets and evaluated model performance metrics, with the primary interest in the sensitivity and increase in the positive predictive value (PPV) compared to a screen-everyone approach.

Results

The model was evaluated on 2510 patients from Mexico (primary care: 1358, tertiary care: 735, ENSANUT-MC: 417). Across the Mexico data, the sensitivity was 0.730 (95% CI: 0.689 - 0.779) and the relative increase in PPV was 61.0% (95% CI: 52.1% - 70.8%). These were not statistically different to the regional performance metrics for the Americas (sensitivity: p=0.964; relative improvement: p=0.132), however considerable variability was observed across the data sources.

Conclusion

The minimal-resource model performs consistently in a representative Mexican population sample compared with the Americas regional performance. In primary care settings where screening is underperformed and access to laboratory testing is limited, the model can act as a risk-tailored CKD screening solution, directing screening resources to patients who are at highest risk.

Examining the Relationship between Dietary Intake, Socioeconomic Status, and Systolic Blood Pressure of Adults on Hemodialysis in Quito, Ecuador

Background

In Ecuador, the number of adults on hemodialysis (HD) continues to rise. Currently, the effect dietary habits and socioeconomic status (SES) have on blood pressure is not known for those on HD.

Objectives

The objectives of this study focused on adults on HD in Quito, Ecuador to 1) assess the relationship between dietary intake and SES; 2) compare dietary intake to the Kidney Disease Outcomes Quality Initiative (KDOQI) guidelines; and 3) explore the relationship between dietary intake and systolic blood pressure.

Methods

This cross-sectional study was conducted at the dialysis center within Eugenio Espejo Specialties Hospital in Quito, Ecuador between May and June 2022 among 50 adults on HD. Three 24-h recalls were used to determine average dietary intake and the 25-item Instituto Nacional de Estadística y Censos-Stratification of SES was used to determine SES. Electrolytes and 2 blood pressure readings were collected. Qualitative narrative data analysis was performed to identify themes using NVivo v12. T-tests of independence, simple, and multiple linear regressions using age and sex as confounders were conducted using R and a P < 0.05 was deemed as statistically significant.

Results

On an average, 76% of participants consumed <25 kcal/kg body weight energy and 64% consumed <1 g protein/kg body weight. Participants consumed less energy and protein compared with the KDOQI guidelines (P < 0.05). Positive relationships were observed with potassium and blood pressure (β = 0.020, P < 0.05) and SES with energy, protein, and phosphorus (P < 0.05). Themes that were identified as contributing to dietary intake were limited knowledge, lack of consistency with dietary information, and limited appetite.

Conclusions

Findings from this study indicate that the focus should be on improving energy and protein intake for this population.

Iron-Deficiency Anemia in CKD: A Narrative Review for the Kidney Care Team

Anemia is a common complication of chronic kidney disease (CKD) and is associated with increased mortality and reduced health-related quality of life. Anemia is characterized by a decrease in hemoglobin, the iron-rich protein that the body uses for oxygen transport. Iron is required to produce hemoglobin, and disruptions in the iron homeostasis can lead to iron-deficiency anemia. Management of anemia in individuals with CKD is typically performed by a team of physicians, nurse practitioners, physician assistants, or registered nurses. Throughout the care continuum, the management can be enhanced by multidisciplinary care, and individuals with CKD can benefit from the involvement of other specialties, with dietitians/nutritionists playing an important role. However, a key area of unmet clinical need is how to assess and address iron-deficiency anemia. This review aims to provide an overview of iron-deficiency anemia in CKD and how this may be diagnosed and managed by the entire kidney care team, such as describing the mechanisms underlying iron homeostasis, the complications of iron-deficiency anemia, and the current challenges associated with its diagnosis and treatment in CKD. Opportunities for each multidisciplinary team member to add value to the care of individuals with CKD and iron-deficiency anemia are also described.

Quality of life and associated factors among chronic kidney disease patients at Zewditu Memorial and Tikur Anbessa Specialised Hospitals, Ethiopia: a cross-sectional study design

INTRODUCTION

Chronic kidney disease (CKD) is associated with significant morbidity, mortality, healthcare cost and reduced health-related quality of life (HRQoL). This study aimed to assess HRQoL and associated factors among patients with CKD at both Zewditu Memorial and Tikur Anbessa Specialised Hospitals, Ethiopia.

METHOD

A cross-sectional study design was performed. All patients who visited the renal clinics in both hospitals from March to July 2019 were targeted, and data were collected using interviews and medical records. HRQoL was assessed using the Kidney Disease and Quality of Life-36 tool. Normality assessment was done for HRQoL subscales. Descriptive statistics, logistic regression, t-test and one-way analysis of variance were performed.

RESULT

A total of 300 patients with CKD were included. Around 62% of them were in either stage 3 or 4 CKD. The mean domain scores of physical component summary (PCS), mental component summary (MCS), burden of kidney disease, effect of kidney disease and symptoms and problems of kidney disease (SPKD) subscales were 50.4, 59.5, 63.1, 74.6 and 80.4, respectively. The lowest HRQoL was seen in the PCS scale, while the highest was in SPKD. In addition, the study revealed that a lower level of education, elevated serum creatinine and a history of smoking were significantly associated with poor PCS score. Further, the presence of three or more comorbidities, CKD-related complications and a lower haemoglobin level were significantly associated with poor MCS.

CONCLUSION

The overall mean scores of PCS and MCS were low, below the standard level. Level of education, serum creatinine and smoking history were significantly associated with PCS, while the presence of comorbidity, complications and haemoglobin level were significantly associated with MCS. Stakeholders working on CKD management should design a relevant strategy targeting patients, patients' care providers and healthcare professionals to improve HRQoL of patients.

Kidney Health and Care: Current Status, Challenges, and Developments

The concept of chronic kidney disease (CKD) originated in the 2000s, and an estimated 850 million patients are currently suffering from health threats from different degrees of CKD. However, it is unclear whether the existing CKD care systems are optimal for improving patient prognosis and outcomes, so this review summarizes the burden, existing care models, effectiveness, challenges, and developments of CKD care. Even under the general care principles, there are still significant gaps in our understanding of the causes of CKD, prevention or care resources, and care burdens between countries worldwide. Receiving care from multidisciplinary teams rather than only a nephrologist shows potential profits in comprehensive and preferable outcomes. In addition, we propose a novel CKD care structure that combines modern technologies, biosensors, longitudinal data visualization, machine learning algorithms, and mobile care. The novel care structure could simultaneously change the care process, significantly reduce human contact, and make the vulnerable population less likely to be exposed to infectious diseases such as COVID-19. The information offered should be beneficial, allowing us to rethink future CKD care models and applications to reach the goals of health equality and sustainability.

Secular trends of epidemiologic patterns of chronic kidney disease over three decades: an updated analysis of the Global Burden of Disease Study 2019

OBJECTIVES

To assess the characteristics of the global death burden imposed by chronic kidney disease (CKD) and the attributable risk factors from 1990 to 2019 to help inform a framework for policy discussions, resource allocation and research priorities.

DESIGN

A population-based observational study.

SETTING

The death data and relative risk factors were obtained from the Global Burden of Disease (GBD) Study 2019 database.

MAIN OUTCOME MEASURES

Based on the GBD database, we estimated the death burden attributable to CKD stratified by sociodemographic index (SDI), geographic location, sex, age group, time period and risk factors from 1990 to 2019.

RESULTS

Over three decade study period, the global number of CKD-related deaths increased from 0.60 million (95% uncertainty interval (UI): 0.57-0.63 million) in 1990 to 1.43 million (95% UI: 1.31-1.52 million) in 2019. The age-standardised death rate (ASDR) of CKD, among all causes, increased from 15th in 1990 to 10th in 2019. Globally, the ASDR in males was higher than that in females. CKD-related deaths mainly occurred in those aged over 50 years, especially in regions with higher SDIs. The ASDR was negatively related to SDI (ρ=-0.603, p<0.0001). Among risk factors, metabolic risk factors, especially systolic blood pressure, fasting plasma glucose and body mass index, were the main contributors to CKD-related deaths. Although the high-temperature-related death burden was low, the trend increased sharply in lower SDI regions.

CONCLUSIONS

CKD-related deaths continue to increase, with the majority occurring in elderly adults. The CKD-related death burden is higher in males than in females. Additionally, the increasing high-temperature-related death burdens in lower SDI regions should receive social attention.

Follow-up of children and adolescents with congenital anomalies of the kidneys and urinary tract, associated with rare hereditary syndromes

The purpose of the study was to evaluate the course and outcome in chronic kidney disease of congenital anomalies of the kidneys and urinary tract (CAKUT) associated with rare hereditary syndromes in children and adolescents, and to compare the results with literature data. The results of a follow-up study of the course and outcome in chronic kidney disease with syndromal congenital anomalies of the kidneys and urinary tract in rare hereditary syndromes (Pierson, Fraser 1 type, Renal hypodysplasia/ aplasia 3 type, Schuurs– Hoeómakers, CHARGE, Lowe, Renal-Coloboma, VACTERL association) and chromosomal abnormalities (Shereshevsky—Terner monosomia 45‡) are presented. In 4 out of 9 children and adolescents with congenital anomalies of the kidneys and urinary tract with rare hereditary syndromes, the formation of chronic kidney disease was established.

Leveraging the South African Diabetes Prevention Programme to screen for chronic kidney disease: an observational study

OBJECTIVE

To evaluate the viability of leveraging an existing screening programme (the South African Diabetes Prevention Programme (SA-DPP)) to screen for chronic kidney disease (CKD), by assessing the yield of CKD cases among those participating in the programme.

DESIGN

Observational study conducted between 2017 and 2019.

SETTING

16 resource-poor communities in Cape Town, South Africa.

PARTICIPANTS

690 participants, aged between 25 and 65 years, identified as at high risk for type 2 diabetes mellitus (T2DM) by the African Diabetes Risk Score.

PRIMARY OUTCOME MEASURE

The prevalence of CKD among those participating in the SA-DPP.

RESULTS

Of the 2173 individuals screened in the community, 690 participants underwent further testing. Of these participants, 9.6% (n=66) and 18.1% (n=125) had screen-detected T2DM and CKD (defined as an estimated glomerular filtration rate (eGFR) of<60 mL/min/1.73 m² and/or albumin-to-creatinine ratio >3 mg/mmol), respectively. Of those with CKD, 73.6% (n=92), 17.6% (n=22) and 8.8% (n=11) presented with stages 1, 2 and 3, respectively. Of the participants with an eGFR <60 mL/min/1.73 m², 36.4% had no albuminuria and of those with normal kidney function (eGFR ≥90 mL/min/1.73 m²), 10.2% and 3.8% had albuminuria stages 2 and 3, respectively. Of those with T2DM and hypertension, 22.7% and 19.8% had CKD, respectively.

CONCLUSION

The fact that almost one in five participants identified as high risk for T2DM had CKD underscores the value of including markers of kidney function in an existing screening programme. By using an opportunistic approach to screen high-risk individuals, those with CKD can be identified and appropriately treated to reduce disease progression.

Up-regulation of the human-specific CHRFAM7A gene protects against renal fibrosis in mice with obstructive nephropathy

Renal fibrosis is a major factor in the progression of chronic kidney diseases. Obstructive nephropathy is a common cause of renal fibrosis, which is also accompanied by inflammation. To explore the effect of human-specific CHRFAM7A expression, an inflammation-related gene, on renal fibrosis during obstructive nephropathy, we studied CHRFAM7A transgenic mice and wild type mice that underwent unilateral ureteral obstruction (UUO) injury. Transgenic overexpression of CHRFAM7A gene inhibited UUO-induced renal fibrosis, which was demonstrated by decreased fibrotic gene expression and collagen deposition. Furthermore, kidneys from transgenic mice had reduced TGF-β1 and Smad2/3 expression following UUO compared with those from wild type mice with UUO. In addition, the overexpression of CHRFAM7A decreased release of inflammatory cytokines in the kidneys of UUO-injured mice. In vitro, the overexpression of CHRFAM7A inhibited TGF-β1-induced increase in expression of fibrosis-related genes in human renal tubular epithelial cells (HK-2 cells). Additionally, up-regulated expression of CHRFAM7A in HK-2 cells decreased TGF-β1-induced epithelial-mesenchymal transition (EMT) and inhibited activation f TGF-β1/Smad2/3 signalling pathways. Collectively, our findings demonstrate that overexpression of the human-specific CHRFAM7A gene can reduce UUO-induced renal fibrosis by inhibiting TGF-β1/Smad2/3 signalling pathway to reduce inflammatory reactions and EMT of renal tubular epithelial cells.

Update on Existing Care Models for Chronic Kidney Disease in Low- and Middle-Income Countries: A Systematic Review

BACKGROUND

Approximately 78% of chronic kidney disease (CKD) cases reside in low- and middle-income countries (LMICs). However, little is known about the care models for CKD in LMICs.

OBJECTIVE

Our objective was to update a prior systematic review on CKD care models in LMICs and summarize information on multidisciplinary care and management of CKD complications.

DESIGN

We searched MEDLINE, EMBASE, and Global Health databases in September 2020, for papers published between January 1, 2017, and September 14, 2020. We used a combination of search terms, which were different iterations of CKD, care models, and LMICs. The World Bank definition (2019) was used to identify LMICs.

SETTING

Our review included studies published in LMICs across 4 continents: Africa, Asia, North America (Mexico), and Europe (Ukraine). The study settings included tertiary hospitals (n = 6), multidisciplinary clinics (n = 1), primary health centers (n = 2), referral centers (n = 2), district hospitals (n = 1), teaching hospitals (n = 1), regional hospital (n = 1), and an urban medical center (n = 1).

PATIENTS

Eighteen studies met inclusion criteria, and encompassed 4679 patients, of which 4665 were adults. Only 9 studies reported mean eGFR which ranged from 7 to 45.90 ml/min/1.73 m2.

MEASUREMENTS

We retrieved the following details about CKD care: funding, urban or rural location, types of health care staff, and type of care provided, as defined by Kidney Disease Improving Global Outcomes (KDIGO) guidelines for CKD care.

METHODS

We included studies which met the following criteria: (1) population was largely adults, defined as age 18 years and older; (2) most of the study population had CKD, and not end-stage kidney disease (ESKD); (3) population resided in an LMIC as defined by the World Bank; (4) manuscript described in some detail a clinical care model for CKD; (5) manuscript was in either English or French. Animal studies, case reports, comments, and editorials were excluded.

RESULTS

Eighteen studies (24 care models with 4665 patients) met inclusion criteria. Out of 24 care models, 20 involved interdisciplinary health care teams. Twenty models incorporated international guidelines for CKD management. However, conservative kidney management (management of kidney failure without dialysis or renal transplant) was in a minority of models (11 of 24). Although there were similarities between all the clinical care models, there was variation in services provided and in funding arrangement; the latter ranged from comprehensive government funding (eg, Sri Lanka, Thailand), to out-of-pocket payments (eg, Benin, Togo).

LIMITATIONS

These include (1) lack of detail on CKD care in many of the studies, (2) small number of included studies, (3) using a different definition of care model from the original Stanifer et al paper, and (4) using the KDIGO Guidelines as the standard for defining a CKD care model.

CONCLUSIONS

Most of the CKD models of care include the key elements of CKD care. However, access to such care depends on the funding mechanism available. In addition, few models included conservative kidney management, which should be a priority for future investment.

TRIAL REGISTRATION

Not applicable.

Critical windows of perinatal particulate matter (PM2.5) exposure and preadolescent kidney function

Air pollution exposure, especially particulate matter ≤2.5 μm in diameter (PM2.5), is associated with poorer kidney function in adults and children. Perinatal exposure may occur during susceptible periods of nephron development. We used distributed lag nonlinear models (DLNMs) to examine time-varying associations between early life daily PM2.5 exposure (periconceptional through age 8 years) and kidney parameters in preadolescent children aged 8-10 years. Participants included 427 mother-child dyads enrolled in the PROGRESS birth cohort study based in Mexico City. Daily PM2.5 exposure was estimated at each participant's residence using a validated satellite-based spatio-temporal model. Kidney function parameters included estimated glomerular filtration rate (eGFR), serum cystatin C, and blood urea nitrogen (BUN). Models were adjusted for child's age, sex and body mass index (BMI) z-score, as well as maternal education, indoor smoking report and seasonality (prenatal models were additionally adjusted for average first year of life PM2.5 exposure). We also tested for sex-specific effects. Average perinatal PM2.5 was 22.7 μg/m3 and ranged 16.4-29.3 μg/m3. Early pregnancy PM2.5 exposures were associated with higher eGFR in preadolescence. Specifically, we found that PM2.5 exposure between weeks 1-18 of gestation was associated with increased preadolescent eGFR, whereas exposure in the first 14 months of life after birth were associated with decreased eGFR. Specifically, a 5 μg/m3 increase in PM2.5 during the detected prenatal window was associated with a cumulative increase in eGFR of 4.44 mL/min/1.732 (95%CI: 1.37, 7.52), and during the postnatal window we report a cumulative eGFR decrease of -10.36 mL/min/1.732 (95%CI: -17.68, -3.04). We identified perinatal windows of susceptibility to PM2.5 exposure with preadolescent kidney function parameters. Follow-up investigating PM2.5 exposure with peripubertal kidney function trajectories and risk of kidney disease in adulthood will be critical.

Urinary proteomics for kidney dysfunction: insights and trends

Introduction: Kidney dysfunction poses a high burden on patients and health care systems. Early detection and accurate prediction of kidney disease progression remains a major challenge. Compared to existing clinical parameters, urinary proteomics has the potential to reveal molecular alterations within the kidney that may alter its function before the onset of clinical symptoms. Thus, urinary proteomics has greater prognostic potential for assessment of kidney dysfunction progression.Areas covered: Advances in urinary proteomics for major causes of kidney dysfunction are discussed. The application of urinary extracellular vesicles for studying kidney dysfunction are discussed. Technological advances in urinary proteomics are discussed. The literature was identified using a database search for titles containing 'proteom*' and 'urin*' and published within the past 5 years. Retrieved literature was manually filtered to retain kidney dysfunctions-related studies.Expert opinion: Despite major advances, diagnosis by urinary proteomics has not been fully applied in any clinical settings. This could be attributed to the complex nature of kidney diseases, in addition to the constraints on study power and feasibility of incorporating mass spectrometry techniques in daily routine analysis. Nevertheless, we are confident that advances in urinary proteomics will soon provide superior insights into kidney disease beyond existing clinical parameters.

Kidney health for everyone everywhere: from prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions-be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.

A Review of Chronic Comorbidities in Adults Living With HIV: State of the Science

ABSTRACT

People living with HIV are living longer, high-quality lives; however, as they age, this population is at increased risk for developing chronic comorbidities, including cardiovascular disease, certain types of cancer (e.g., lung, anal, and liver), and diabetes mellitus. The purpose of this state-of-the-science review is to provide an evidence-based summary on common physical comorbidities experienced by people living and aging with HIV. We focus on those chronic conditions that are prevalent and growing and share behavioral risk factors that are common in people living with HIV. We will discuss the current evidence on the epidemiology, physiology, prevention strategies, screening, and treatment options for people living with HIV across resource settings.

Perceptions of chronic kidney disease among at-risk adults in rural Guatemala

This qualitative study explores perceptions of chronic kidney disease (CKD) among adults with abnormal estimated glomerular filtration rate (eGFR) in Guatemala, where the burden of CKD is rising. Qualitative semi-structured interviews were conducted with 39 individuals screened for CKD and found to have abnormal eGFR (defined as <90 mL/min/1.73 m2, per Kidney Disease Improving Global Outcomes [KDIGO] guidelines). Interviews occurred in participants' homes in Spanish or Kaqchikel Mayan. Interview notes were coded for dominant themes through an inductive approach. Interviewees had limited awareness of diabetes and hypertension as CKD risk factors, but appreciated the progressive nature of the disease. While most reported willingness to pursue renal replacement therapies, if necessary, they anticipated economic and geographic barriers. Public health interventions should focus on the association between diabetes, hypertension, and CKD. Improvement of primary care and screening infrastructure is imperative in CKD prevention in low- and middle-income countries (LMICs).

Effectiveness of integrated care on delaying chronic kidney disease progression in rural communities of Thailand (ESCORT-2) trials

AIM

We conducted a prospective cohort study to evaluate the effectiveness of an integrated care model on delaying chronic kidney disease (CKD) progression in routine clinical practice in rural primary care setting.

METHODS

After enrolment, patients with stages 3 to 4 CKD patients from five district hospitals in a northern province of Thailand (400 km from Bangkok) received integrated care comprising hospital multidisciplinary care and home visits by community care teams. Clinical characteristics and biochemical data were collected at baseline and every 3-month interval thereafter for 36 months. The primary outcome was the rate of estimated glomerular filtration rate (eGFR) decline.

RESULTS

Nine hundred and fourteen stage -3 and - 4 CKD patients were enrolled. The mean age of our cohort was 62 years. Diabetic kidney disease (DKD) was the main cause of CKD (53%) whereas hypertension was the most common co-morbidity (92%). The mean rate of eGFR decline was -0.92 mL/min/1.73 m2 /year. The rate of eGFR decline among patients with DKD was about three times faster than patients without DKD. Patients with higher blood pressure, metabolic acidosis, proteinuria or anaemia had a faster rate of eGFR decline.

CONCLUSION

This integrated care model at the community level was effective in delaying CKD progression in routine clinical practice situation.

Kidney Health for Everyone Everywhere - From prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions - be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.

Availability and Affordability of Kidney Health Laboratory Tests around the Globe

BACKGROUND

Kidney disease is a major global public health problem, and laboratory testing of kidney health measures is essential for diagnosis and monitoring. The availability and affordability of kidney health laboratory tests across countries has not been systematically described.

METHODS

The International Society of Nephrology (ISN), in partnership with leaders of a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference, surveyed a representative subset of ISN-Global Kidney Health Atlas (ISN-GKHA) respondents from April to June 2020. We assessed the association between country gross national income (GNI) per capita and laboratory testing availability and affordability.

RESULTS

Of 33 regional expert nephrologists invited, 24 (73%) responded, representing all 10 ISN regions around the world. Availability of kidney health laboratory tests was as follows: serum Cr (100%), serum cystatin C (67%), urine albumin (96%), urine Cr (100%), and dipstick urinalysis (100%). Median (IQR) reimbursement values in international dollars were as follows: serum Cr Int$ 6.61 (3.42-8.84), serum cystatin C Int$ 31.51 (17.36-46.25), urine albumin Int$ 10.22 (5.90-15.42), urine Cr Int$ 7.50 (1.66-8.84), and dipstick urinalysis Int$ 6.26 (2.56-8.40). Reimbursement values did not differ significantly by World Bank income group or by GNI per capita.

CONCLUSION

There was widespread availability of kidney health laboratory tests and substantial variation in reimbursement values. To achieve meaningful progress across nations in mitigating the growth of kidney disease, access to affordable diagnostic technology is essential. Our results are highly relevant to policymakers and researchers as countries increasingly consider national strategies for kidney disease detection and management.

Sustainable Development Goals relevant to kidney health: an update on progress

Globally, more than 5 million people die annually from lack of access to critical treatments for kidney disease — by 2040, chronic kidney disease is projected to be the fifth leading cause of death worldwide. Kidney diseases are particularly challenging to tackle because they are pathologically diverse and are often asymptomatic. As such, kidney disease is often diagnosed late, and the global burden of kidney disease continues to be underappreciated. When kidney disease is not detected and treated early, patient care requires specialized resources that drive up cost, place many people at risk of catastrophic health expenditure and pose high opportunity costs for health systems. Prevention of kidney disease is highly cost-effective but requires a multisectoral holistic approach. Each Sustainable Development Goal (SDG) has the potential to impact kidney disease risk or improve early diagnosis and treatment, and thus reduce the need for high-cost care. All countries have agreed to strive to achieve the SDGs, but progress is disjointed and uneven among and within countries. The six SDG Transformations framework can be used to examine SDGs with relevance to kidney health that require attention and reveal inter-linkages among the SDGs that should accelerate progress.

Working towards sustainable development is essential to tackle the rise in the global burden of non-communicable diseases, including kidney disease. Five years after the Sustainable Development Goal agenda was set, this Review examines the progress thus far, highlighting future challenges and opportunities, and explores the implications for kidney disease.

Each Sustainable Development Goal (SDG) has the potential to improve kidney health and prevent kidney disease by improving the general health and well-being of individuals and societies, and by protecting the environment.

Achievement of each SDG is interrelated to the achievement of multiple other SDGs; therefore, a multisectoral approach is required.

The global burden of kidney disease has been relatively underestimated because of a lack of data.

Structural violence and the social determinants of health have an important impact on kidney disease risk.

Kidney disease is the leading global cause of catastrophic health expenditure, in part because of the high costs of kidney replacement therapy.

Achievement of universal health coverage is the minimum requirement to ensure sustainable and affordable access to early detection and quality treatment of kidney disease and/or its risk factors, which should translate to a reduction in the burden of kidney failure in the future.

Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

In an era of shifting global agendas and expanded emphasis on non-communicable diseases and injuries along with communicable diseases, sound evidence on trends by cause at the national level is essential. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) provides a systematic scientific assessment of published, publicly available, and contributed data on incidence, prevalence, and mortality for a mutually exclusive and collectively exhaustive list of diseases and injuries.

METHODS

GBD estimates incidence, prevalence, mortality, years of life lost (YLLs), years lived with disability (YLDs), and disability-adjusted life-years (DALYs) due to 369 diseases and injuries, for two sexes, and for 204 countries and territories. Input data were extracted from censuses, household surveys, civil registration and vital statistics, disease registries, health service use, air pollution monitors, satellite imaging, disease notifications, and other sources. Cause-specific death rates and cause fractions were calculated using the Cause of Death Ensemble model and spatiotemporal Gaussian process regression. Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. Deaths were multiplied by standard life expectancy at each age to calculate YLLs. A Bayesian meta-regression modelling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. We considered results in the context of the Socio-demographic Index (SDI), a composite indicator of income per capita, years of schooling, and fertility rate in females younger than 25 years. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.

FINDINGS

Global health has steadily improved over the past 30 years as measured by age-standardised DALY rates. After taking into account population growth and ageing, the absolute number of DALYs has remained stable. Since 2010, the pace of decline in global age-standardised DALY rates has accelerated in age groups younger than 50 years compared with the 1990-2010 time period, with the greatest annualised rate of decline occurring in the 0-9-year age group. Six infectious diseases were among the top ten causes of DALYs in children younger than 10 years in 2019: lower respiratory infections (ranked second), diarrhoeal diseases (third), malaria (fifth), meningitis (sixth), whooping cough (ninth), and sexually transmitted infections (which, in this age group, is fully accounted for by congenital syphilis; ranked tenth). In adolescents aged 10-24 years, three injury causes were among the top causes of DALYs: road injuries (ranked first), self-harm (third), and interpersonal violence (fifth). Five of the causes that were in the top ten for ages 10-24 years were also in the top ten in the 25-49-year age group: road injuries (ranked first), HIV/AIDS (second), low back pain (fourth), headache disorders (fifth), and depressive disorders (sixth). In 2019, ischaemic heart disease and stroke were the top-ranked causes of DALYs in both the 50-74-year and 75-years-and-older age groups. Since 1990, there has been a marked shift towards a greater proportion of burden due to YLDs from non-communicable diseases and injuries. In 2019, there were 11 countries where non-communicable disease and injury YLDs constituted more than half of all disease burden. Decreases in age-standardised DALY rates have accelerated over the past decade in countries at the lower end of the SDI range, while improvements have started to stagnate or even reverse in countries with higher SDI.

INTERPRETATION

As disability becomes an increasingly large component of disease burden and a larger component of health expenditure, greater research and development investment is needed to identify new, more effective intervention strategies. With a rapidly ageing global population, the demands on health services to deal with disabling outcomes, which increase with age, will require policy makers to anticipate these changes. The mix of universal and more geographically specific influences on health reinforces the need for regular reporting on population health in detail and by underlying cause to help decision makers to identify success stories of disease control to emulate, as well as opportunities to improve.

FUNDING

Bill & Melinda Gates Foundation.

Current Management Strategies of Chronic Kidney Disease in Resource-Limited Countries

The incidence and prevalence of chronic kidney disease (CKD) and kidney failure continues to increase worldwide, especially in resource-limited countries. Many countries in this category already have a massive burden of communicable diseases, as well as socio-economic and socio-demographic challenges. The rising CKD burden and exorbitant economic cost associated with treatment are mainly responsible for the alarming mortality rate associated with kidney disease in these regions. There is often poor risk factor (diabetes and hypertension) and CKD awareness in these countries and limited availability and affordability of treatment options. Given these observations, early disease detection and preventive measures remain the best options for disease management in resource-limited settings. Primary, secondary and tertiary preventive strategies need to be enhanced and should particularly include measures to increase awareness, regular assessment to detect hypertension, diabetes and albuminuria, options for early referral of identified patients to a nephrologist and options for conservative kidney management where kidney replacement therapies may not be available or indicated. Much is still needed to be done by governments in these regions, especially regarding healthcare funding, improving the primary healthcare systems and enhancing non-communicable disease detection and treatment programs as these will have effects on kidney care in these regions.

Kidney health for everyone everywhere-from prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD are often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions-be it primary, secondary, or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, the management of comorbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management, and treatment are often lacking. Hence, there is an urgent need to increase awareness of the importance of preventive measures throughout populations, professionals, and policy makers.

A comparison of HIV outpatient care in primary and secondary healthcare-level settings in Zimbabwe

Setting

Decentralisation of HIV care to nurse-led primary care services is being implemented across low- and middle-income countries in sub-Saharan Africa.

Objective

To compare services offered to clients attending for HIV care at a physician-led and a nurse-led service in Harare, Zimbabwe.

Design

A cross-sectional study was performed at Harare Central Hospital (HCH) and Budiriro Primary Care Clinic (PCC) from June to August 2018. An interviewer-administered questionnaire was used to collect sociodemographics, HIV treatment and clinical history from clients attending for routine HIV care. The Mann-Whitney U-test was used to evaluate for differences between groups for continuous variables. For categorical variables, the χ² test was used.

Results

The median age of the 404 participants recruited was 38 years (IQR 28-47); 69% were female. Viral suppression was comparable between sites (HCH, 70% vs. PCC, 80%; P = 0.07); however, screening for comorbidities such as cervical cancer screening (HCH, 61% vs. PCC, 41%; P = 0.001) and provision of referral services (HCH, 23% vs. PCC, 13%; P = 0.01) differed between sites.

Conclusion

Efforts to improve service provision in primary care settings are needed to ensure equity for users of health services.

[Kidney health for everyone everywhere - from prevention to detection and equitable access to care]

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can beimplemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.

Kidney Health for Everyone Everywhere - From Prevention to Detection and Equitable Access to Care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions - be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.

Health care trajectories and barriers to treatment for patients with end-stage renal disease without health insurance in Mexico: a mixed methods approach

Background

Mexico has the sixth-highest premature death rate from chronic kidney disease (CKD) in the world. From 1990 to 2017, the age-standardized CKD mortality rate jumped from 28.7 to 58.1 per 100,000 inhabitants, making it the second-leading cause of death that year. Medical care for the disease is inequitable, as those without health insurance have limited access to renal replacement therapy (RRT). The objective of this study is to describe the healthcare trajectories of patients with end-stage renal disease (ESRD) in a public hospital in Mexico City and the barriers they face in receiving peritoneal dialysis and haemodialysis.

Methods

This study uses a convergent mixed methods approach and is predominantly qualitative. Patients completed 199 surveys, and 42 semi-structured interviews with patients having ESRD and their families were conducted. The quantitative data were analysed using descriptive statistics, and the qualitative data were processed using a phenomenological approach.

Results

It was found that 76.9% of the patients received peritoneal dialysis or haemodialysis as their first RRT. Over 30% began their treatment at least a month after a health professional prescribed it. Almost 50% had been hospitalized for complications related to the disease in the previous year, and 36% had uncertainties about their treatment. Close to 64% of the haemodialysis patients received treatment intermittently. Barriers to accessing treatment, information, contact with health services, and treatment availability were identified. Patients and their families encountered economic and emotional difficulties at every phase of their search for medical care and treatment.

Conclusion

Mexico urgently needs to implement public policies related to CKD that are primarily directed at its prevention but should also implement policies directed at slowing its progression, reducing its complications, and providing funding for uninsured patients who require RRT. These policies must be based on the perspectives of human rights and equality, and the perspectives of patients, their families and the general population should be included in the policy creation process.

Kidney health for everyone everywhere - from prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions - be it primary, secondary or tertiary. This complementing article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals and policy makers.

Rate of uncontrolled blood pressure and its associated factors in patients with predialysis chronic kidney disease in Bali, Indonesia

Purpose

Hypertension is a key determinant for the development and progression of chronic kidney disease (CKD). The purpose of this study is to assess the rate of uncontrolled blood pressure (BP) and identify its associated factors in patients with predialysis CKD in Bali, Indonesia.

Design/methodology/approach

A cross-sectional study was conducted among 165 patients who attended the nephrology clinic in a central public hospital in Bali. Data were obtained by measuring BP at threshold 130/80 mmHg, as well as collected through standardized questionnaires. Univariate analysis was done using Chi-square test, and multivariate analyses were carried out using multiple logistic regression.

Findings

A total of 165 patients (111 males and 54 females) with predialysis CKD participated in this study. About 64% of the participants had uncontrolled BP. In multiple logistic regression, all selected variables significantly explained 63.2% of the variance in uncontrolled BP. However, low physical activity (odds ratio [OR] = 24.287, 95% confidence interval [CI]: 3.114–189.445), unhealthy dietary pattern (OR = 10.153, 95% CI: 2.770–37.210), as well as perceived moderate stress (OR = 4.365, 95% CI: 1.024-18.609) and high stress (OR = 10.978, 95% CI: 2.602–46.312) were significantly associated with uncontrolled BP.

Research limitations/implications

The study findings provide evidence for health care providers to improve BP control among patients with predialysis CKD.

Originality/value

Controlling BP among patients with predialysis CKD was poor. Lifestyle modification and stress management are keys to improving BP control.

Kidney Health for Everyone Everywhere: From Prevention to Detection and Equitable Access to Care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the fifth most common cause of years of life lost globally by 2040. Aggravatingly, CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual health care budget in high-income countries. Crucially, however, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions—be it primary, secondary, or tertiary. This article complements this initiative by focusing on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with preexisting kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of comorbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to disseminate the preventive approach. While national policies and strategies for noncommunicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management, and treatment are often lacking. Hence, there is an urgent need to increase the awareness of the importance of preventive measures throughout populations, professionals, and policy makers.

Kidney health for everyone everywhere - from prevention to detection and equitable access to care

The global burden of chronic kidney disease (CKD) is rapidly increasing with a projection of becoming the 5th most common cause of years of life lost globally by 2040. CKD is a major cause of catastrophic health expenditure. The costs of dialysis and transplantation consume up to 3% of the annual healthcare budget in high-income countries. However, the onset and progression of CKD is often preventable. In 2020, the World Kidney Day campaign highlights the importance of preventive interventions – be it primary, secondary, or tertiary. This article focuses on outlining and analyzing measures that can be implemented in every country to promote and advance CKD prevention. Primary prevention of kidney disease should focus on the modification of risk factors and addressing structural abnormalities of the kidney and urinary tracts, as well as exposure to environmental risk factors and nephrotoxins. In persons with pre-existing kidney disease, secondary prevention, including blood pressure optimization and glycemic control, should be the main goal of education and clinical interventions. In patients with advanced CKD, management of co-morbidities such as uremia and cardiovascular disease is a highly recommended preventative intervention to avoid or delay dialysis or kidney transplantation. Political efforts are needed to proliferate the preventive approach. While national policies and strategies for non-communicable diseases might be present in a country, specific policies directed toward education and awareness about CKD screening, management, and treatment are often lacking. Hence, there is an urgent need to increase the awareness of preventive measures throughout populations, professionals, and policy makers.