Comment

The major global burden of chronic kidney disease

Chronic kidney disease is a global public health problem, prevalence is unexpected because of the high prevalence See Articles page e382

involving about 10% of the global population.1 The of apolipoprotein L1 mutations, a major risk factor for
awareness of this major burden is relatively recent chronic kidney disease, in populations of recent sub-
and still incomplete. Unfortunately, the multifaceted Saharan African ancestry.4 The authors do not discuss
burden of chronic kidney disease (prevalence, morbidity, KRT quality (frequency and duration of haemodialysis
mortality, costs) is relentlessly growing, particularly in sessions, availability of modern immunosuppressive
low-income countries (LIC).1 drugs, etc). In addition, they just mention that half of
In The Lancet Global Health, Aminu K Bello and countries provided some public funding for chronic
colleagues update the International Society of kidney disease care before KRT. Finally, the paper had
Nephrology Global Kidney Health Atlas, which assesses only a small component devoted to patients’ voices
disparities in kidney disease burden and care across regarding the impact of KRT on their quality of life.
around 200 countries.2 The report relies on a detailed In addition to reducing the above-mentioned
review of the literature, available databases and limitations, the next iteration(s) should expand on
registries to estimate the burden of chronic kidney chronic kidney disease care before KRT. Indeed, kidney
disease, the incidence and prevalence of treated kidney failure treated by KRT is just the costly tip of the chronic
failure. Findings were triangulated with data from a kidney disease iceberg. Morbidity and mortality from
multinational survey of opinion leaders based on WHO’s chronic kidney disease mostly occur before KRT and are
building blocks for health systems (ie, health financing, largely driven by cardiovascular disease. Whereas until
service delivery, access to essential medicines and recently, the tools to delay progression of chronic kidney
technology, health information systems, workforce, and disease were limited to antihypertensive and renin
governance). The authors deserve to be congratulated angiotensin system blockers, chronic kidney disease
for this colossal effort. The global median prevalence care now moves into the direction of multidrug therapy.
of chronic kidney disease is 9·5% (IQR 5·9–11·7). Multiple trials have demonstrated that SGLT2 inhibitors
Haemodialysis (defined as provided to >50% of people reduce hard kidney outcomes and cardiovascular events
with kidney failure, a minimalist definition) is available in patients with albuminuric chronic kidney disease,
in 162 (98%) of 165 surveyed countries, whereas both with and without diabetes.1,5 Finerenone, a non-
peritoneal dialysis and kidney transplantation are steroidal mineralocorticoid receptor antagonist, has
available in about three-quarters of countries. The been approved for the management of chronic kidney
prevalence of kidney replacement therapy (KRT, either disease in patients with type 2 diabetes.6 Thus, the
dialysis or kidney transplantation) varies by a factor Kidney Disease: Improving Global Outcomes (KDIGO)
200 from high-income regions (highest in Taiwan) to global guidelines recommend the use of both SGLT2
LIC such as sub-Saharan Africa countries. Within LICs, inhibitors and finerenone in appropriate patients. This
wide disparities in KRT availability depend on political wave of new chronic kidney disease drugs is likely to
or public health agendas of individual countries. The continue: indeed, a phase 3 finerenone study is ongoing
workforce for kidney care increased somewhat recently, in non-diabetic albuminuric chronic kidney disease. An
but the number of nephrologists remains very low in endothelin-receptor antagonist and an aldosterone
LIC. In almost 50% of surveyed countries, funding for synthase inhibitor will soon be tested in phase 3 trials,
KRT expenses relies solely on private and out-of-pocket after positive phase 2 studies.7,8 In addition, a large as
payments.2 yet unpublished trial with semaglutide, a GLP1 agonist,
The global picture captured by this report is was terminated because an interim analysis by the
important. Unsurprisingly, for such a massive effort, independent Data Monitoring Committee concluded
some results raise questions or point to limitations. In that prespecified criteria were met for stopping the trial
Africa, the authors report a 4·2% prevalence of chronic early for efficacy on the primary kidney outcome.9
kidney disease, which is much lower than the prevalence But drugs’ registration is just the end of the beginning
in other recent reports (12·2–15·8%).3,4 This low of the battle. Indeed, the role of many health-care

www.thelancet.com/lancetgh Vol 12 March 2024 e342

 Comment

physicians, not just nephrologists, but also primary care *Michel Jadoul, Mabel Aoun, Mannix Masimango Imani
physicians, cardiologists, endocrinologists, and others [email protected]
caring for patients with undiagnosed chronic kidney Cliniques universitaires Saint Luc, Université Catholique de Louvain, 1200
Brussels, Belgium (MJ); AUB Santé, Lorient, France (MA); Faculty of Medicine,
disease will be key. The recent position statement from Saint-Joseph University of Beirut, Beirut, Lebanon (MA); Faculty of Medicine,
the American Heart Association10 on the cardio-kidney Université Catholique de Bukavu, Bukavu, Democratic Republic of Congo (MMI);
Department of Internal Medicine, Hôpital Provincial Général de Référence de
metabolic syndrome (whose earlier diagnosis is possible Bukavu, Bukavu, Democratic Republic of Congo (MMI)
by urinalysis, when eGFR is still normal) is noteworthy. 1 Kidney Disease: Improving Global Outcomes (KDIGO) CKD Work Group.
KDIGO 2024 Clinical Practice Guideline for the Evaluation and Management
Collaboration between medical specialties, patients, of Chronic Kidney Disease. Kidney Int 2024; 105: S1–S197.
and public health organisations will be important to 2 Bello AK, Okpechi IG, Levin A, et al. An update on the global disparities in
kidney disease burden and care across world countries and regions.
increase the prescription of drugs effectively delaying Lancet Glob Health 2024; 12: e382–95.
progression of chronic kidney disease. Admittedly, 3 Kaze AD, Ilori T, Jaar BG, Echouffo-Tcheugui JB. Burden of chronic kidney
disease on the African continent: a systematic review and meta-analysis.
having a prescription is not enough. Access to new BMC Nephrol 2018; 19: 125.
medications is required and remains poor in low-income 4 Masimango MI, Jadoul M, Binns-Roemer EA, et al. APOL1 renal risk variants
and sickle cell trait associations with reduced kidney function in a large
and middle-income countries. Hence, additional efforts Congolese population-based study. Kidney Int Rep 2021; 7: 474–82.
5 Mark PB, Sarafidis P, Ekart R, et al. SGLT2i for evidence-based cardiorenal
from WHO and policy makers is needed to make such protection in diabetic and non-diabetic chronic kidney disease: a
medications globally available. comprehensive review by EURECA-m and ERBP working groups of ERA.
Nephrol Dial Transplant 2023; 38: 2444–55.
In conclusion, the report by Bello and colleagues 6 Agarwal R, Filippatos G, Pitt B, et al. Cardiovascular and kidney outcomes
highlights that additional advocacy efforts are urgently with finerenone in patients with type 2 diabetes and chronic kidney
disease: the FIDELITY pooled analysis. Eur Heart J 2022; 43: 474–84.
needed for the inclusion of chronic kidney disease care in 7 Heerspink HJL, Kiyosue A, Wheeler DC, et al. Zibotentan in combination
the global health agenda. KRT funding is insufficient and with dapagliflozin compared with dapagliflozin in patients with chronic
kidney disease (ZENITH-CKD): a multicentre, randomised, active-
policies for care are missing in most countries. Future controlled, phase 2b, clinical trial. Lancet 2023; 402: 2004–17.
8 Tuttle KR, Hauske SJ, Canziani ME, et al. Efficacy and safety of aldosterone
action plans should improve awareness of the burden of synthase inhibition with and without empagliflozin for chronic kidney
chronic kidney disease and promote early detection and disease: a randomised, controlled, phase 2 trial. Lancet 2023; published
online Dec 15. https://doi.org/10.1016/S0140–6736(23)02408-X.
management in high-risk groups, training of additional 9 Novo Nordisk. Novo Nordisk will stop the once-weekly injectable
health-care practitioners, and provision of essential semaglutide kidney outcomes trial, FLOW, based on interim analysis.
Oct 10, 2023. https://www.novonordisk.com/news-and-media/news-and-
medicines for patients with chronic kidney disease. ir-materials/news-details.html?id=166327 (accessed Jan 17, 2024).
MJ is cochair of Kidney Disease: Improving Global Outcomes (KDIGO), which 10 Ndumele CE, Neeland IJ, Tuttle KR, et al. A synopsis of the evidence for the
science and clinical management of Cardiovascular-Kidney-Metabolic
publishes the global guidelines in nephrology; he has been a consultant or
(CKM) syndrome: a scientific statement from the American Heart
speaker for AstraZeneca, Bayer, and Boehringer-Ingelheim. The other authors Association. Circulation 2023; 148: 1636–64.
declare no competing interests.
Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open
Access article under the CC BY-NC-ND 4.0 license.

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