Improving Global Kidney Health

Improving Global Kidney Health

  • Post category:Expert Speak
  • Reading time:14 mins read

Background

Chronic Kidney Disease (CKD) is a major public health problem and is increasingly being recognized as an important driver of costs in all health care systems. The diversity of outcomes for people living with CKD is in part due to variability in biology, access to care, environmental factors, and health care system differences. 

The International Society of Nephrology (ISN), working in collaboration with its partners, has evolved into a philanthropic organization, from a traditional medical society, committed to a vision that sees “a future where all people have access to sustainable kidney health”. A set of activities, including a Global Kidney Health Summit, the Global Kidney Health Atlas, and a Global Kidney Health Policy Forum, which has formed the basis of a multi-stakeholder engagement process, building on a solid base of ISN programs and educational activities, is described.

Through building awareness and increasing the capacity to conduct research, the international community will build a more solid foundation on which to advocate for sustainable, ethical solutions to the problem of kidney disease throughout the world.

Global Kidney Health

As a cause of years of life lost, CKD has moved from 25th (1990) to 21st (2005), and17th (2015) worldwide⁵.  International estimates of CKD have been consistently between 10 and 16% of the adult population ⁷, ⁸, though there have been some reports of lower rates⁹,¹⁰. Estimates of prevalence have reported variability in different parts of the world⁸, ¹¹, ¹². In a 12-country report involving over 75,000 persons, the prevalence of CKD was 14% among the general populations and 36% among high-risk populations. 

Diabetes and hypertension remain major drivers of CKD in most parts of the world. This has not been systematically evaluated yet; however, as the prevalence of diabetes increases worldwide (estimates of 592 million people by 2035), the implications for the prevalence of CKD are astounding. The clinical problem facing faced by global citizens is the various differences that exist in access to prevention and treatment, access to dialysis and transplantation, and access to trained health care professionals. Unfortunately, most of the individuals with CKD globally do not have access to renal replacement therapies.

A systematic analysis reported in the Lancet 2015 ¹³ by Liyange and colleagues estimates that between 27 and 53% of patients needing renal replacement therapy (RRT) receive it, and thus between 2 and 7 million people in the world do not have access to RRT when reaching end-stage kidney failure. Environmental, social, and genetic factors play a role in access to care within and between countries¹⁴-¹⁶. There are recognized perverse incentives for dialysis modalities in many locations around the world, and many challenges prevail with regard to access to transplantation. Ethical approaches to dialysis and transplantation have been described in recent publications¹⁷.

The ISN, founded in 1960 as a traditional medical society, has evolved over the last 50 years and has developed a broad set of activities, which are directed to meeting the new vision statement, “a future where all people have equitable access to sustainable kidney health”. The ISN’s mission is to bridge the gaps of available care through advocacy and collaborations with global partners; build the capacity of health care professionals through granting programs, education, and research; and connect with local, global, and professional communities to develop stronger understandings of the management of kidney diseases.

The ISN recognizes that both Acute Kidney Injury (AKI) and CKD are global problems and challenging for all, and thus continue to build on programs and activities to work toward achieving the mission.  In order to better understand the kidney diseases, the ISN launched a series of additional activities including the first Global Kidney Health Summit¹⁹-²⁸, a Global Kidney Health Atlas (GKHA) and  ISN Global Policy Forums. The GKHA describes kidney care  using the 6 dimensions of Universal Health Coverage.

125 countries were surveyed, representing 93% of the world population. Country capacity, readiness, and response for optimal kidney care were assessed according to the 6 domains of Universal Health Care: health workforce, health service delivery, essential medicines and technologies, health financing, leadership, governance, and health information systems. 

Key findings included the vast variability of the nephrology workforce relative to population, with inverse proportions in low- and middle-income countries (LMIC) compared to high-income countries (HIC); lack of official registries for AKI, CKD, dialysis, and transplantation in most parts of the world, and variation in health care services available for the identification of CKD by primary care. Not surprisingly, diversity existed in the availability of dialysis services for acute and chronic conditions; even in those locations with availability, not all people had access to dialysis services due to economic, geographic, or other reasons. Furthermore, the capacity of research is limited to HIC, despite the large population base in LMIC and low-income countries. 

The GKHA describes for the first time, the current state of CKD care across low-income countries, LMIC, middle-income countries, HIC, and demonstrates inter- and intra-regional variability in current capacity for kidney care and important gaps in services, facilities, and workforce. There are key opportunities for engaging key governmental and nongovernmental stakeholders to support improving kidney care, and through use of a scorecard process, creates accountability that will help with developing policy and changing practice over time, as part of the global health agenda.

Through these various activities, we have identified that integrated approaches to kidney health are needed: better data from existing registries; organized work on the economic impact of kidney diseases on countries; collaboration with and outside of the health care profession; and better research activities across all pillars of basic, translational, clinical, and population research. 

If we commit to better understanding through descriptive studies, well-designed physiological studies, and large clinical trials, we may advance understanding and develop a more solid evidence base. Paradoxically, the resources for the treatment of kidney diseases worldwide far outweigh the evidence base that informs clinical care: the investments by government and research funding bodies seem disproportionate to the expenditures on care. 

The ISN has committed to increasing research capacity through a number of distinct activities. To date, more than 81 clinical research grants have been awarded to LMIC; and ISN Advancing Clinical Trials have been established⁴¹ to enhance the capacity of all regions to conduct clinical trials, and to facilitate the cultural change necessary to promote clinical trials.

Summary 

Through this integrated approach to improve kidney health, the international community in general, and the ISN in particular, are in a much stronger position to advocate for sustainable kidney health. The ISN, with all of its partners and collaborators, is proud to be providing innovative approaches and solutions; measuring and documenting progress; and providing a strong voice focusing on kidney diseases around the globe.

While CKD is recognized as a public health problem, change is happening through collaborative activities such as basic science and translational consortia, patient-oriented research consortia, and collaborative clinical trials networks. This change, based on new knowledge, new paradigms, and new policies, has great potential to improve global kidney health.

Credits

Adeera Levin,  Ann Nutr Metab 2018;72(suppl 2):28–32  https://doi.org/10.1159/000488123

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