Global Challenges and Progress in Kidney Health

Key Points

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The global burden of chronic kidney disease (CKD) is rising. Impaired kidney function is the seventh leading global risk factor for death.
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In lower-income regions CKD occurs in younger individuals.
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The global burden of acute kidney injury remains unknown.
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Impaired kidney function contributes to more deaths from cardiovascular disease than from end-stage kidney failure.
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Many countries lack policies regarding kidney disease advocacy, screening, and prevention.
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Achieving universal health coverage may reduce the global burden of acute kidney injury and CKD through improved access to primary care and essential diagnostics and medication.
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Access to dialysis and transplantation is highly inequitable across the globe and within regions and countries, largely dictated by ability to pay and presence of government policies.
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If dialysis and/or transplantation are to be provided in low-resource settings, rigorous planning must be done up front to determine affordability and to ensure sustainability, and transparent criteria must be developed to achieve fairness and equitable access to kidney replacement therapy.

Global Challenges in Kidney Health

Kidney Disease is an Important Public Health Concern

Kidney disease is an important noncommunicable disease (NCD) worldwide; however, this is not yet widely acknowledged on the global policy agenda. The World Health Organization (WHO) Global Action Plan for the Prevention and Control of NCDs initially prioritized four main diseases (heart diseases and stroke, cancer, chronic respiratory diseases, and diabetes) and four main risk factors (diet, physical activity, alcohol, and tobacco) in a 4 × 4 campaign, having identified these four diseases as the major NCD killers globally. Subsequently, mental health and air pollution were added to become a 5 × 5 campaign. In 2023, oral health was included as a priority NCD, and it has been suggested that sugar be added to expand to a 6 × 6 campaign. Kidney disease has therefore not consistently been identified as a global priority, although it is likely that kidney health has benefited from campaigns aimed at improving adherence to healthy lifestyles.

The global importance of kidney disease as a cause of mortality and morbidity is increasing. Impaired kidney function (IKF—defined as an estimated glomerular filtration rate [eGFR] <60 mL/min/L·73 m ² or albumin-to- creatinine ratio [ACR] ≥to 30 mg/g) has been identified as the 7th global leading cause of death ( Table 73.1 ) and has risen to the 10th leading global cause of death as listed by the WHO. ^, If this trend continues, it has been projected that kidney disease may become the fifth leading global cause of years of life lost (YLLs) by 2040.

Table 73.1

Global Burden of Chronic Kidney Disease (CKD, Mean Estimates with 95% Uncertainty Intervals)

Parameter	CKD		CVD due to IKF		IKF Total
Prevalence
Number, 2019	697.3 mln	(650.0-741.1)	—		—
Crude rate/100,000 population, 2019	9011.9	(8401.3-9577.8)	—		—
Global rank, 2019	13th		—		—
Change in number from 1990 to 2019, %	104.1%	(100.9-107.3)	—		—
Change in crude rate from 1990 to 2019, %	41.1%	(38.9-43.4)	—		—
Change in age-standardized rate from 1990 to 2019, %	9.4%	(8.7-10.3)	—		—
YLDs
Number, 2019	8.7 mln	(6.3-11.5)	2.3 mln	(1.6-3.1)	11.3 mln	(8.2-14.7)
Crude rate/100,000 population, 2019	113.0	(81.7-148.7)	29.8	(20.7-40.0)	145.8	(106.4-189.7)
Global rank, 2019	26th		–		10th
Change in number from 1990-2019, %	125.6%	(116.6-134.6)	119.1%	(114.1-124.4)	125.5%	(118.3-132.7)
Change in crude rate from 1990-2019, %	56.0%	(49.8-62.2)	51.5%	(48.0-55.2)	55.9%	(50.9-60.9)
Change in age-standardized rate from 1990-2019, %	24.3%	(20.6-27.7)	5.4%	(3.0-7.5)	20.2%	(16.9-23.2)
Deaths
Number, 2019	1.4 mln	(1.3-1.5)	1.7 mln	(1.3-2.2)	3.2 mln	(2.7-3.6)
Crude rate/100,000 population, 2019	18.4	(17.0-19.7)	22.4	(17.1-28.0)	40.9	(35.2-46.8)
Global rank, 2019	11th		—		7 ^th
Change in number from 1990-2019, %	137.4%	(118.7-153.6)	78.7%	(67.3-90.8)	101.2%	(88.4-112.9)
Change in crude rate from 1990-2019, %	64.1%	(51.2-75.3)	23.6%	(15.7-31.9)	39.1%	(30.3-47.2)
Change in age-standardized rate from 1990-2019, %	13.3%	(4.6-20.4)	–23.0%	(–27.5-–18.5)	–10.0%	(–15.5-–4.6)
YLLs
Number, 2019	32.8 mln	(30.5-35.0)	32.4 mln	(25.3-40.1)	65.2 mln	(57.2-73.5)
Crude rate/100,000 population, 2019	423.8	(393.6-453.0)	418.9	(327.3-518.2)	842.7	(739.5-950.1)
Global rank, 2019	16th		—		10th
Change in number from 1990 to 2019, %	86.0%	(72.9-100.0)	66.6%	(54.7-78.2)	75.8%	(64.6-87.4)
Change in crude rate from 1990 to 2019, %	28.6%	(19.6-38.3)	15.2%	(6.9-23.2)	21.6%	(13.8-29.6)
Change in age-standardized rate from 1990 to 2019, %	2.3%	(–4.9-9.5)	–21.8%	(–27.0-–16.4)	–11.3%	(–17.1-–5.6)
DALYs
Number, 2019	41.5 mln	(38.3-45.0)	34.7 mln	(27.5-42.7)	76.5 mln	(67.8-86.3)
Crude rate/100,000 population, 2019	536.9	(494.9-582.1)	448.7	(354.9-552.3)	988.5	(876.1-1115.2)
Global rank, 2019	18th		—		10th
Change in number from 1990 to 2019, %	93.2%	(81.6-105.0)	69.3%	(58.1-80.6)	81.7%	(71.6-92.0)
Change in crude rate from 1990 to 2019, %	33.6%	(25.6-41.7)	17.0%	(9.3-24.8)	25.6%	(18.6-32.8)
Change in age-standardized rate from 1990 to 2019, %	6.3%	(0.2-12.4)	–20.5%	(–25.5-–15.5)	–7.7%	(–12.9-–2.4)

IKF (impaired kidney function) includes low glomerular filtration rate and albuminuria. It is considered to be a risk factor resulting in the burden of CKD, cardiovascular disease (CVD), and gout.

Global rank for CKD refers to a rank among 369 diseases and injuries; global rank for IKF refers to a rank among 87 risk factors expressed as a crude rate.

As discussed in detail later, estimates from the Global Burden of Disease (GBD) study in 2019 showed that around 1.4 million people died of chronic kidney disease (CKD) and kidney dysfunction contributed to a further 1.7 million deaths from cardiovascular diseases (CVD). Others have estimated that between 2 and 7 million people died in 2010 because they had no access to dialysis and 1.7 million die annually from acute kidney injury (AKI). ^, It is possible therefore that kidney disease may contribute to 6–11 million deaths annually, many of these thus far uncounted.

AKI and CKD are both of public health concern. Although the true prevalence of both in low-income (LIC) and lower-middle-income countries (LMICs), collectively LLMICs, is unknown, it is estimated that they are at least as high, if not higher, than in high-income countries (HICs). Approximately 700 million adults (8%–16%) worldwide are living with CKD, around 80% of whom reside in low or middle-income countries. ^, Up to 90% of those affected however are not aware of their condition. ^, The prevalence of CKD among children is unknown but may reach 1%. Traditional and universal risk factors for CKD include diabetes and hypertension, although additional risk factors for CKD are being increasingly recognized including nephrotoxins (prescription medication and traditional/complementary remedies), kidney stones, fetal and maternal exposures, infections, environmental and occupational exposures, and AKI. ^, The contribution of such nontraditional risk factors to the burdens of AKI and CKD is unknown but may be significant, especially in LLMIC. The impact of climate change and its consequences is also increasingly being recognized as an important contributor to both acute and chronic kidney disease.

Global data on the burden of AKI are lacking; however, from systematic reviews the incidence of AKI in hospitalized patients has been reported to be 7% to 21% (30%–70% of critically ill patients) worldwide. ^, AKI has been estimated to affect 13.3 million people per year, of whom around 85% reside in LLMIC. Data for children are again relatively scarce, with estimates of 7.5% to 23.3% among hospitalized children depending on the definitions used. Overall mortality has been estimated at 11% to 23% in adults and 14% in children but varies with the population studied, reaching 80% if no dialysis is available when required. ^, ^, AKI is associated with high costs of care as many patients require intensive care management. Indeed, mortality is lower in countries with higher expenditure on health care, reflecting better access to health care and dialysis in these countries. ^, ^, In higher-income countries the majority of AKI is hospital acquired, whereas in many LLMICs, community-acquired AKI is more common. ^, Sepsis, dehydration, use of nephrotoxins, and primary acute kidney injury are major universal causes of AKI, with tropical infections and obstetric causes being common in lower-resource settings. In many patients with AKI, kidney function will recover, but adults and children experiencing AKI have an up to eightfold risk of developing CKD and are at increased risk of longer-term CVD and death. CKD, in turn, is an important risk factor for AKI. For further discussion of AKI, see Chapters 27 and 28 .

Challenges in diagnosis of kidney disease include the necessity for access to blood and urine testing, awareness among health care workers, a degree of therapeutic nihilism in environments where access to specialist care and dialysis is limited, and the fact that kidney disease is often asymptomatic or symptoms are nonspecific until advanced stages. ^, Proactive screening for early detection of AKI or CKD in high-risk individuals, to permit interventions to delay worsening of the disease, is therefore required. Increased awareness of risk factors for CKD and AKI in communities and hospitalized populations is urgently needed to successfully implement prevention strategies. Kidney disease risk may begin early with low birth weight or preterm birth (see Chapter 20) and accumulate across the life span, often exacerbated by the social determinants of health. ^, Kidney disease also bridges communicable and noncommunicable diseases. Acute infections such as malaria and leptospirosis may lead to AKI, and chronic infections such as hepatitis B and C and HIV are important causes of CKD. ^, In turn, AKI and CKD increase the risk and morbidity of infections. Many people worldwide are therefore affected by kidney disease, at least some of which is preventable. ^, Despite the best efforts at prevention, however, some people will develop either acute or end-stage kidney failure and require kidney replacement therapy (dialysis or transplantation, KRT) to remain alive.

The public health importance of CKD lies in not only the risk of end-stage kidney failure (ESKF) requiring dialysis and/or transplantation, at great expense to the individual and the health system, but also in the fact that CKD is a major risk multiplier of cardiovascular risk, contributing to excess strokes and heart attacks and leading to death of many CKD patients before they ever reach ESKF. It is frequently underappreciated that CKD alone is a stronger risk factor for coronary events than diabetes, and when the two conditions coexist (which occurs in one in three patients with diabetes), the risk of cardiovascular events and overall mortality is further multiplied. ^, In addition, people living with kidney disease are among those with the greatest multimorbidity and have a high degree of complexity, requiring frequent hospitalizations, and at significant cost almost equaling that of KRT. ^,

In recent years various initiatives have been launched or supported by the global nephrology community to improve understanding of the burden of kidney disease, estimate the resources available to tackle kidney disease, advocate for kidney health, and contribute to the development of innovative strategies to prevent or detect and treat kidney disease early. Some of these initiatives are described as follows.

Global Burden of Disease Study—Kidney Disease

The Global Burden of Disease, Injuries and Risk Factors (GBD) study presents a comprehensive assessment of the global epidemiology of CKD as both a direct cause of mortality and morbidity and a risk factor for CVD. The CKD metrics are available at the global and regional levels, as well as for 204 countries and territories from 1990 to 2019. Compared with previous estimates, the latest GBD revision covering 2019 provides data for all CKD stages burden (previously limited to stages 3–5) and evaluates both albuminuria and low GFR as risk factors under the umbrella term “impaired kidney function (IKF)” (previously limited only to low GFR). The GBD uses the term “IKF” to indicate the impact of CKD as a risk factor for ischemic heart disease, stroke, peripheral vascular disease, and gout, as well as to differentiate it from the term “CKD” itself, which refers to a direct cause of morbidity and mortality due to kidney disease.

For CKD and other diseases, the GBD provides several innovative metrics including years lived with disability (YLDs), YLLs due to premature death, and disability-adjusted life years (DALYs). DALYs are a unified measure of disease burden that summarizes YLLs and YLDs, thus accounting for both mortality and morbidity. For each metric both crude (all ages) and age-standardized rates per 100,000 population are available. Age standardization was done to the 2019 world population, reporting rates adjusted to differences in age structure, and thus allows comparison of rates in different countries and across years for the same country. Generally, crude rates are higher in HICs, mostly due to the longer life duration and higher proportion of older individuals, while age-standardized rates are much higher in LMICs, indicating more young individuals of working age affected by CKD.

Chronic Kidney Disease Prevalence

Global CKD prevalence amounted to 697.3 million in 2019 (see Table 73.1 , Fig. 73.1 ) which corresponds to 9.0% of the world’s population. This estimate is higher than the prevalence of CVD, neoplasms, diabetes mellitus, chronic obstructive pulmonary disease, osteoarthritis, or the number of people living with the consequences of road injury ( Fig. 73.2 ). ^, CKD prevalence was 13.1% of global population aged 20 years and older and substantially increased with age. CKD was more prevalent in females (382.7 million) than in males (314.3 million). The majority of CKD cases in 2019 were assumed to be due to intrinsic or unknown etiology of the kidney disease (531.1 million), followed by diabetic nephropathy (134.6 million) and hypertensive nephropathy (31.0 million); however, these estimates are based on data from a minority of world countries and require data on CKD etiology from LMICs to become more precise.

A bar graph shows prevalence in 2019 and the change in prevalence from 1990 to 2019 for six diseases. Chronic kidney disease is second in both the graphs. The bar graph contains two adjacent sections. The section on the left displays the prevalence of selected diseases in 2019 in million persons, with the horizontal axis ranging from 0 to 1000. Six horizontal bars are shown from top to bottom and labeled mental disorders, chronic kidney disease, cardiovascular diseases, neoplasms, diabetes mellitus, and chronic respiratory diseases. The bar for mental disorders is the longest, followed by chronic kidney disease, then cardiovascular diseases, neoplasms, diabetes mellitus, and chronic respiratory diseases. The section on the right shows the change in age-standardized prevalence rate between 1990 and 2019 in percent, with the horizontal axis ranging from negative 20 percent to positive 60 percent in increments of 20 percent. Six horizontal bars are shown from top to bottom and labeled diabetes mellitus, chronic kidney disease, mental disorders, cardiovascular diseases, neoplasms, and chronic respiratory diseases. The diabetes mellitus bar is the longest, pointing toward the right. The chronic kidney disease bar is shorter, pointing toward the right. The bars for mental disorders, cardiovascular diseases, and neoplasms are shorter and also point rightward. The bar for chronic respiratory diseases points toward the left. — Fig. 73.2

The GBD estimates are close to those from independent meta-analyses that estimated the CKD prevalence to be 13.4% (with 10.6% attributed to stages 3–5) globally and 14.3% (with 9.8% attributed to stages 3–5) in geographically dispersed lower-resource countries. However, the GBD has the substantial advantage of broader and more detailed data inclusion, age standardization, and, most importantly, availability of CKD estimates for each country. Almost a third of global subjects with CKD in 2019 lived in two countries: China (150.5 million, accounting to 10.6% of the population) and India (115.2 million, equal to 8.2% of the population). Brazil, Indonesia, Japan, Mexico, Pakistan, Philippines, Russia, Thailand, and the United States of America each had more than 10 million people with CKD, 14 additional countries had between 5 and 10 million CKD patients, and another 48 countries had from 1 to 5 million persons with CKD ( Figs. 73.3 and 73.4 ).

A world map shows country-level chronic kidney disease prevalence metrics with a triangular color scale at the bottom left labeled with three axes. The map shows a global distribution of countries filled with different colors representing chronic kidney disease prevalence metrics. At the bottom left, a triangle-shaped reference scale is shown with three labeled axes. The left axis is labeled normalized all-ages rate, the right axis is labeled normalized age-standardized rate, and the vertical axis is labeled normalized change in age-standardized rate between 1990 and 2019, percent. The three axes are labeled with numerical values 25, 50, and 75. Each point inside the triangle is filled with a gradient of colors. — Fig. 73.3

A chart shows world regions sized by the number of chronic kidney disease patients in 2019, with labels showing regional names and corresponding values in millions. The chart is a rectangular layout divided into labeled blocks, each representing a world region with a corresponding number of chronic kidney disease patients in 2019. At the top center is Central Europe, labeled 13.6 million. To its left is Western Europe, labeled 17.7 million, and below that is Eastern Europe, labeled 30.1 million. Further left is South Asia, labeled 139.5 million, and below it is Southeast Asia, labeled 71.1 million. Left of South Asia is East Asia, labeled 156.8 million. Below Southeast Asia is Central Asia, labeled 8.2 million. Below Central Asia is Southern Latin America, labeled 5.7 million. Adjacent to Eastern Europe on the right is North Africa and the Middle East, labeled 49.8 million. To the right of it is North America, labeled 44.0 million. Below Eastern Europe is Central Latin America, labeled 29.5 million. The right of Central Latin America is Tropical Latin America, labeled 17.9 million. Below Tropical Latin America is Andean Latin America, labeled 5.3 million. Below Andean Latin America is the Caribbean, labeled 4.3 million. To the right of the Caribbean is the Asia Pacific, labeled 31.0 million. Below Asia Pacific is Oceania, labeled 0.9 million, and to the right of Oceania is Australasia, labeled 2.9 million. To the right of Asia Pacific is Western Sub-Saharan Africa, labeled 17.7 million. Below that is Eastern Sub-Saharan Africa, labeled 13.9 million. Further below is Central Sub-Saharan Africa, labeled 4.5 million, and to the bottom right is Southern Sub-Saharan Africa, labeled 5.0 million. — Fig. 73.4

Compared with 1990, the GBD study reported significant increase in the prevalence of CKD of 104.1% in absolute numbers, 41.1% in crude rates, and 9.4% in age-standardized rates. The latter observation is important as it indicates the continuous increase of CKD prevalence is independent of changes in population age structure. Of note, the majority of NCDs over the same period demonstrated a decrease in age-standardized rates (see Fig. 73.2 ) due to successful reduction in risk factor exposure.

The GBD confirmed significant heterogeneity between countries and regions (see Figs. 73.3 and 73.5 ), with crude prevalence rates being much higher in HICs and age-standardized rates being higher in LLMICs. The highest age-standardized CKD prevalences in 2019 were found in Central Latin America, Southeast Asia, North Africa, and the Middle East—and these regions also demonstrated the highest increase in age-standardized rates of >20% (see Fig. 73.5 ). In contrast, many HICs showed a small increase or even a decline in age-standardized CKD rates since 1990 (see Figs. 73.3 and 73.5 ). This fact could suggest differences in causes, progression rates, and mortality of CKD by income region, or lack of access to early detection and treatment of CKD in lower-income regions. It is well recognized that important differences in access to and quality of kidney care exist between different countries, ^, and even within the same country different populations have higher risks of late referral to nephrology services. Taken together, the higher frequency among younger individuals, limited access to kidney care, and inadequate access to essential medications contribute to the CKD burden, which has important implications for national economies, especially in countries with lower socioeconomic development. ^, ^,

A graph displays all-ages and age-standardized chronic kidney disease rates for 1990 and 2019, at both global and regional levels, with percent changes indicated for each. The figure consists of two side-by-side graphs. The horizontal axis of the left graph is labeled all-ages rate per 100000 population and ranges from 0 to 20000 without marked intervals. The horizontal axis of the right graph is labeled age-standardized rate per 100000 population and ranges from 0 to 20000 without marked intervals. Both graphs share a vertical axis with grouped regional labels. In the left graph, the first horizontal row is labeled Global, showing a left circular marker representing the year 1990 and a right circular marker representing the year 2019, connected by a horizontal line, with the percentage plus 41 percent written to the right. The following rows are as follows Caribbean with plus 63 percent, Oceania with plus 22 percent, Eastern Europe with plus 33 percent, Central Europe with plus 60 percent, Western Europe with plus 38 percent, Australasia with plus 46 percent, Asia Pacific with plus 74 percent, Central Asia with plus 36 percent, East Asia with plus 57 percent, South Asia with plus 41 percent, Southeast Asia with plus 59 percent, Andean Latin America with plus 82 percent, Central Latin America with plus 88 percent, Southern Latin America with plus 49 percent, Tropical Latin America with plus 73 percent, North America with plus 29 percent, North Africa with plus 79 percent, Eastern Sub-Saharan Africa with plus 16 percent, Central Sub-Saharan Africa with plus 13 percent, Southern Sub-Saharan Africa with plus 46 percent, and Western Sub-Saharan Africa with plus 12 percent. Each entry contains two circular markers and a horizontal line. In the right graph, the regions are listed in the same order. Global shows plus nine percent, Caribbean plus twenty-four percent, Oceania plus 10 percent, Eastern Europe plus 10 percent, Central Europe plus 15 percent, Western Europe plus 4 percent, Australasia plus 6 percent, Asia Pacific shows a decrease of minus 2 percent, Central Asia plus 17 percent, East Asia plus 2 percent, South Asia plus 8 percent, Southeast Asia plus 16 percent, Andean Latin America plus 30 percent, Central Latin America plus 23 percent, Southern Latin America plus 16 percent, Tropical Latin America plus 14 percent, North America plus 3 percent, North Africa plus 38 percent, Eastern Sub-Saharan Africa plus 10 percent, Central Sub-Saharan Africa plus 11 percent, Southern Sub-Saharan Africa plus 17 percent, and Western Sub-Saharan Africa plus 16 percent. Each region is shown with two circular markers, the left for the year 1990 and the right for the year 2019, connected by a horizontal line. At the far right of the figure is a legend with a lighter circular marker labeled 1990 and a darker circular marker labeled 2019. — Fig. 73.5

Mortality Due to Chronic Kidney Disease

Importantly, kidney disease represents both a direct cause of morbidity and mortality and is a risk factor for morbidity and mortality from other diseases. Worldwide in 2019, CKD directly resulted in 1.4 million deaths, and 1.7 million deaths occurred due to IKF as a risk factor for CVD ( Fig. 73.6 ). Thus the overall mortality from IKF was 3.2 million, which makes it the seventh leading cause of death that resulted in 1 in 17 fatal outcomes in the world (see Table 73.1 ). Of note, compared with 1990, the dynamics of the two IKF mortality components were different. The first component, mortality from CKD as a direct cause of death, increased by 137.4% in absolute numbers, by 64.1% in crude rates, and by 13.3% in age-standardized rates (see Table 73.1 ). The highest rates and greatest increase in CKD mortality over 30 years were detected in Latin America and Southern Africa, while in some regions the improved access to KRT for older people led to a decrease in age-standardized rates ( Figs. 73.7–73.9 ). While the number of deaths from CKD is much lower than from CVD and comparable with those for diabetes, CKD remains one of the few causes of death that is still increasing ( Fig. 73.10 ). This increase made CKD the 11th leading cause of death in 2019 according to the GBD study, compared with its ranking of 19th in 1990, and it is expected to increase further by 2040 to 2.2 million in a best-case scenario and up to 4.0 million in a worst-case scenario, to become the fifth leading cause of YLLs. In contrast, the second component, CVD deaths attributable to IKF as a risk factor, decreased by–23.0% in age-standardized rates because of widespread implementation of prevention programs aimed to fight CVD.

A four-pie chart shows global deaths from chronic kidney disease and cardiovascular disease due to impaired kidney function from 1990 to 2019. The four pie charts are displayed from left to right, representing the years 1990, 2000, 2010, and 2019. Each pie chart is labeled at the top with the total number of deaths in millions and at the bottom with the year. The first pie chart is labeled 1.6 million at the top and 1990 at the bottom. It is divided into two segments with labels on the right: C K D 0.6 million and C V D 1.0 million. The second pie chart is labeled 2.0 million at the top and 2000 at the bottom, with segments labeled C K D 0.8 million and C V D 1.2 million. The third pie chart is labeled 2.5 million at the top and 2010 at the bottom, with segments labeled C K D 1.1 million and C V D 1.4 million. The fourth and largest pie chart is labeled 3.2 million at the top and 2019 at the bottom, with segments labeled C K D 1.4 million and C V D 1.7 million. Arrows point from each segment to its corresponding label. — Fig. 73.6

A world map shows country-level mortality metrics for chronic kidney disease with a triangular scale at the bottom left labeled with three axes and numeric values. The map shows continents with countries filled with different shades. Each country represents mortality metrics for chronic kidney disease. At the bottom left, a triangle-shaped reference scale is present and filled with a gradient and small dots scattered throughout. The left side of the triangle is labeled normalized all-ages rate and has tick marks at 25, 50, and 75. The right side is labeled normalized age-standardized rate with tick marks at 25, 50, and 75. The vertical side is labeled normalized change in age-standardized rate between 1990 and 2019, percent, with tick marks at 25, 50, and 75. The map includes large and small countries and island regions. — Fig. 73.7

A chart shows world regions sized by the number of deaths due to chronic kidney disease in 2019, with region names and death counts labeled inside each block. The chart is subdivided into labeled regions, each with a number in parentheses indicating deaths due to chronic kidney disease in 2019. The largest block at the top left is South Asia, labeled 285342. To its right is East Asia, labeled 209292. Beneath South Asia is Southeast Asia, labeled 153371. Beneath Southeast Asia is Central Asia, labeled 10381. To the right of Central Asia is Western Europe, labeled 116656. Inside Western Europe are two smaller vertically stacked rectangles, as Central Europe is labeled 18762 and Eastern Europe is labeled 15931. To the right of East Asia is Central Latin America, labeled 111705. Above Central Latin America are two small horizontal rectangles, as Southern Latin America is labeled 21693, and Andean Latin America is labeled 19382. Beneath Central Latin America is Tropical Latin America, labeled 44219. To the right of Central Latin America is North Africa and the Middle East, labeled 111812. To the right of North Africa and the Middle East is the Asia Pacific, labeled 54139. Beneath Asia Pacific is the Caribbean, labeled 12664. Beneath the Caribbean is Oceania, labeled 1598. To the right of Oceania is Australasia, labeled 6122. To the right of North Africa and the Middle East is Western Sub-Saharan Africa, labeled 52474. Above it is Central Sub-Saharan Africa, labeled 12358. To the right of Central Sub-Saharan Africa is Eastern Sub-Saharan Africa, labeled 38598. Above Eastern Sub-Saharan Africa is Southern Sub-Saharan Africa, labeled 16267. The rightmost rectangle is North America, labeled 114465. — Fig. 73.8

A graphs show all-ages and age-standardized chronic kidney disease mortality rates per 100000 population in 1990 and 2019 by region, with percent changes labeled. The graph includes two side-by-side graphs. The horizontal axis of the left graph is labeled all-ages rate per 100000 population, and the horizontal axis of the right graph is labeled age-standardized rate per 100000 population. The vertical axis lists regions grouped by Global, Europe, Asia, Latin America, North America, North Africa, and Africa. Each graph shows circular markers for the years 1990 and 2019 connected by horizontal lines, with percentage change labeled to the right of each pair. In the left graph, Global shows an increase of plus 64 percent, Caribbean plus 98 percent, Oceania plus 26 percent, Eastern Europe plus 55 percent, Central Europe plus 54 percent, Western Europe plus 107 percent, Australasia plus 111 percent, Asia Pacific plus 119 percent, Central Asia plus 53 percent, East Asia plus 67 percent, South Asia plus 48 percent, Southeast Asia plus 55 percent, Andean Latin America plus 122 percent, Central Latin America plus 254 percent, Southern Latin America plus 79 percent, Tropical Latin America plus 82 percent, North America plus 147 percent, North Africa plus 20 percent, Eastern Sub-Saharan Africa minus 18 percent, Central Sub-Saharan Africa minus 19 percent, Southern Sub-Saharan Africa plus 76 percent, and Western Sub-Saharan Africa minus 19 percent. In the right graph, Global shows plus 13 percent, Caribbean plus 32 percent, Oceania plus 14 percent, Eastern Europe plus 10 percent, Central Europe plus 17 percent, Western Europe plus 16 percent, Australasia plus 47 percent, Asia Pacific minus 30 percent, Central Asia plus 1 percent, East Asia plus 40 percent, South Asia plus 87 percent, Southeast Asia plus 22 percent, Andean Latin America minus 2 percent, Central Latin America plus 72 percent, Southern Latin America minus 13 percent, Tropical Latin America minus 11 percent, North America minus 15 percent, North Africa plus 41 percent, and Eastern Sub-Saharan Africa minus 8 percent. A legend in the upper right shows lighter circular markers for 1990 and darker circular markers for 2019. — Fig. 73.9

Bar graphs compare global mortality from selected noncommunicable diseases. The left graph shows deaths in 2019, right graph shows the percent change in age-standardized death rate from 1990 to 2019. The graph includes two bar graphs displayed side by side. The horizontal axis of the left graph is labeled deaths for selected diseases in 2019, million, and ranges from 0 to 25 in increments of 5. Five horizontal bars are stacked from top to bottom and labeled cardiovascular diseases, neoplasms, chronic respiratory diseases, diabetes mellitus, and chronic kidney disease. The bar for cardiovascular diseases extends slightly beyond 20 million, neoplasms to about 10 million, chronic respiratory diseases to about 4 million, diabetes mellitus slightly above 1 million, and chronic kidney disease just below 1 million. The horizontal axis of the right graph is labeled change in age-standardized death rate between 1990 and 2019, percent, and ranges from minus 40 percent to 20 percent in increments of 20 percent. Five horizontal bars are shown from top to bottom and labeled chronic kidney disease, diabetes mellitus, neoplasms, cardiovascular diseases, and chronic respiratory diseases. The bar for chronic kidney disease extends just past plus 20 percent, diabetes mellitus slightly above 0 percent, neoplasms slightly below 0 percent, cardiovascular diseases to about minus 10 percent, and chronic respiratory diseases extend farthest to the left, slightly past minus 40 percent. — Fig. 73.10

A different approach to estimation of CKD mortality, based on the comparison of actual provision of KRT and estimated need for KRT suggested that between 2.3 and 7.1 million deaths worldwide could be attributable to death from ESKF due to lack of access to KRT. Determining the exact number of deaths related to CKD is challenging because of the lack of access to diagnosis of CKD in many lower-income regions, differences in mortality coding practices, competitive categorical mortality attribution (CKD vs. CVD), and lack of precise data from many countries. Nevertheless, even with the available data, the mortality burden from kidney disease is huge and requires urgent implementation of CKD prevention and treatment programs everywhere.

YLDS, YLLS, DALYS Due to Chronic Kidney Disease

Worldwide in 2019, YLDs directly related to CKD accounted for almost 8.7 million, and those related to CVD and gout attributable to IKF accounted for 2.3 million and 0.2 million, respectively (see Table 73.1 ). This corresponds to 1 of every 76 global YLDs from all diseases, an important number, considering that the vast majority of individuals with CKD stages 1 to 3 are not included in the YLDs due to the GBD methodology. Regarding the burden expressed in YLLs, the impact reached 32.8 million for CKD as a direct cause of death and 32.4 million for CVD deaths attributed to IKF as a risk factor. Together, this equals 65.2 million YLLs, which makes IKF the 10th leading cause of YLL globally. Both YLDs and YLLs substantially increase with age ( Fig. 73.11 ).

A horizontal bar graph shows years of life lost and years lived with disability per 100000 population in males and females by age group for chronic kidney disease in 2019. The horizontal bar graph is split into two sections, with males on the left and females on the right, centered around age groups listed vertically in the middle from bottom to top as less than 28 days, 28 to 364 days, 1 to 4 years, 5 to 9 years, 10 to 14 years, 15 to 19 years, 20 to 24 years, 25 to 29 years, 30 to 34 years, 35 to 39 years, 40 to 44 years, 45 to 49 years, 50 to 54 years, 55 to 59 years, 60 to 64 years, 65 to 69 years, 70 to 74 years, 75 to 79 years, 80 to 84 years, and 85 plus years; the horizontal axis is labeled rate per 100000 population and ranges from 0 to 5500 in both directions with tick marks at every 1000; each bar is divided into a segment representing years lived with disability and an orange segment representing years of life lost, with the full length representing disability-adjusted life years; for males, the orange segment is longest in the 85 plus years group followed by 80 to 84 years and 75 to 79 years, with very small segments visible from 45 to 49 years and increasing slightly through older age groups; for females, the longest bar is also in the 85 plus years group followed by 80 to 84 years and 75 to 79 years, with bars more visible than in males, especially from 60 to 64 years and upward; for both sexes, the bars are minimal or nearly absent in age groups below 15 years, a legend at the bottom center identifies the segment as years lived with disability and the segment as years of life lost; the top of the graph is labeled males and females above their respective sections. — Fig. 73.11

In terms of DALYs, CKD directly led to 41.5 million and IKF as a risk factor for CVD and gout led to 34.7 million and 0.2 million, respectively ( Fig. 73.12 ). Overall, this indicates that 1 of every 33 DALYs in the world was due to IKF, making it the 10th leading risk factor for DALYs. Considering both absolute count, crude, and age-standardized DALY rates per 100,000 population, IKF outranked factors such as alcohol use, unsafe sanitation, low physical activity, drug use, and many nutritional deficiencies. Considering the change in age-standardized DALY rates between 1990 and 2019, there was an increase of 6.3% for CKD and a decrease of–20.5% for CVD due to IKF. The regional and country dynamics were heterogeneous, and the increase in age-standardized DALY rates over 30 years were highest in the regions with the highest CKD burdens—Central and Andean Latin America, the Caribbean, Southern Africa, and Oceania. These regions require focused efforts to reduce the excessive CKD burdens.

Four pie charts show disability-adjusted life years from chronic kidney disease, cardiovascular disease, and gout related to impaired kidney function from 1990 to 2019. The figure displays four pie charts arranged from left to right, labeled below with the years 1990, 2000, 2010, and 2019, and labeled above with total values of 42.1 million, 52.5 million, 64.4 million, and 76.5 million, respectively. Each pie chart is divided into three labeled segments with corresponding values. The 1990 chart shows gout 0.1 million, chronic kidney disease 21.5 million, and cardiovascular disease 20.5 million. The 2000 chart shows gout 0.1 million, chronic kidney disease 27.4 million, and cardiovascular disease 25.0 million. The 2010 chart shows gout 0.2 million, chronic kidney disease 34.6 million, and cardiovascular disease 29.7 million. The 2019 chart shows gout 0.2 million, chronic kidney disease 41.5 million, and cardiovascular disease 34.7 million. — Fig. 73.12

The GBD provides some data on the risk factors for the development of CKD ( Fig. 73.13 ). Although these estimates are not complete due to lack of data from many countries, they do help to understand the global landscape and prioritize targeting of the major risk factors, such as high systolic blood pressure, high fasting plasma glucose, and high body mass index.

A bar graph shows all-ages disability-adjusted life years in millions for multiple risk factors of chronic kidney disease in 1990, 2000, 2010, and 2019, with colored bars for each factor. The bar graph presents all-ages disability-adjusted life years in millions for seven risk factors across the years 1990, 2000, 2010, and 2019. The horizontal axis shows the years 1990, 2000, 2010, and 2019. The vertical axis is labeled all-ages disability-adjusted life years number, million, and ranges from 0 to 25 in increments of 5. Each group of bars corresponds to one year and includes bars for systolic blood pressure, high plasma glucose, high body mass index, low temperature, lead exposure, and high temperature. In 1990, the bar for systolic blood pressure reached slightly above 9 million, high plasma glucose about 6 million, high body-mass index about 3 million, low temperature about 1 million, lead exposure about 0.5 million, and high temperature barely above zero. In 2000, systolic blood pressure reaches just below 14 million, high plasma glucose about 8 million, high body-mass index about 5 million, low temperature around 1 million, lead exposure about 0.5 million, and high temperature still near zero. In 2010, systolic blood pressure bar reaches around 17 million, high plasma glucose about 10 million, high body-mass index about 7 million, low temperature around 1 million, lead exposure near 0.5 million, and high temperature slightly above zero. In 2019, systolic blood pressure reaches nearly 22 million, high plasma glucose around 13 million, high body-mass index slightly above 11 million, low temperature still around 1 million, lead exposure close to 0.5 million, and high temperature remains barely above zero. A legend in the top left identifies each color-coded risk factor. — Fig. 73.13

Drivers of Epidemiologic Transition for Chronic Kidney Disease

The change in CKD epidemiology in recent decades has occurred because of various factors. Firstly, CKD morbidity and mortality are related to the global processes of population growth, aging, and migration. The world’s population has grown from 5.3 billion in 1990 to 7.7 billion in 2019, median global age increased from 23 to 30 years, life expectancy increased from 65 to 73 years, and the percentage of urban population changed from 43.0% to 55.2% in the same period. These changes directly impact the epidemiology of CKD, with absolute counts of CKD patients increasing in proportion to population growth and aging, and possibly also to improved health outcomes in the urban populations. This epidemiologic transition also drives the metabolic and nutritional risk factors for CKD development and progression. Thus over 29 years, the CKD age-standardized DALY rates attributable to arterial hypertension have increased by 15.0%, to high fasting plasma glucose by 12.6%, to high body mass index by 78.1%. During the same period, however, the DALY rates attributable to these risk factors have decreased in the case of CVD.

A second factor impacting CKD epidemiology is the absence of universal health coverage (UHC) in many LMICs or lack of access to KRT even in countries formally considered to have UHC. The lack of access to essential medicines for almost 2 billion persons in the world leads to inability to correct risk factors and treat early CKD stages, which fuels morbidity. A shortage of nephrology services results in late referral and higher rates of complications and mortality. The lack of universal access to life-saving KRT fuels mortality, and the shortage of kidney transplant facilities increases the total cost of maintenance of KRT. The world’s most socially vulnerable regions suffer the most because even after the start of dialysis, a vast majority of patients are forced to withdraw from this life-saving treatment (up to 85% of the incident patients) and die because of inability to pay for KRT. ^,

A third important driver of CKD growth, especially relevant to the increase in LMICs, is the persistent inequality among different population subgroups in exposure to risk factors, as well as access to prevention and treatment. Countries with lower economic development have higher rates of CKD and NCDs in general. However, even within the same country substantial inequalities exist in access to medical care, particularly KRT. ^, Thus in many regions medical care for rural populations is insufficiently developed, and one would expect a higher mortality from CKD and ESKF even if the prevalence of CKD risk factors might be lower in rural settings. CKD is also more prevalent among the urban poor than those of higher socioeconomic status in developed countries (see Chapter 81 ). Other vulnerable groups include women, older persons, and children who in many societies still have reduced access to medical treatment. Women have higher CKD prevalence and generally lower rates of kidney disease progression as compared with men, but there is also evidence of lower access to kidney treatment for women. ^, Moreover, CKD in pregnant women substantially increases the odds of preeclampsia, preterm delivery, small for gestational age, and low birth weight, all factors associated with low nephron number and increased risks of CKD and other non-communicable diseases over the life course (see Chapter 20). ^, Thus persisting inequalities and lack of attention to women’s health forms a vicious circle that contributes to the CKD burden over generations. It could be speculated that current higher age-standardized rates of CKD burden in LLMIC may in part be impacted by suboptimal fetal and early childhood nutrition and development leading to later-life CKD. Future generations may see the impact of the current humanitarian crises scattered over all continents on fetal health and CKD epidemiology over the coming decades.

A fourth reason underlying the CKD epidemiologic transition is the increase in CKD burden in certain countries and whole regions independent of changes in the general population. Significant increase in age-standardized CKD rates across regions highlight the most problematic countries where investigation is urgently needed to examine and address the factors leading to increasing age-standardized rates. An example of such an emerging CKD epidemic is Mesoamerican nephropathy (more probably a group of nephropathies also termed CKD of unknown etiology, CKDu), which affects predominantly adult agricultural workers in subequatorial countries of Central America and South Asia. The available data have not permitted an estimate of the burden of CKDu over time, but in some regions such as Nicaragua, CKD is the number 1 cause of death, fueled by the epidemic of CKDu. See Chapter 83 for a more detailed discussion of CKDu. Additional evidence, not well represented in the scientific literature, suggests that other groups of workers (metal and diamond miners, industrial paintshop workers, and others) with high exposure to environmental or occupational hazards are also affected by nephropathies that require further investigation and efforts at prevention. It is possible that worldwide, millions of people work or live in unsafe environments, which add to the global CKD burden.

Finally, CKD prevalence estimates depend on the precision of eGFR equations (i.e., the correspondence between measured and estimated GFR) and availability of repetitive testing to confirm chronic persistence of abnormal kidney disease markers. Use of different GFR estimation equations may lead to an up to 30% difference in CKD prevalence estimates. ^, The GBD accounts for this and applied an adjustment for different eGFR equations by a special cross-walk procedure, setting the CKD-EPI (version 2009) as the reference. However, any eGFR equation inherits a substantial imprecision and requires verification in different ethnic and age subgroups, which so far has not been performed in many nations suffering from the highest CKD rates, and should be implemented in the future.

The International Society of Nephrology Global Kidney Health Atlas

As part of the “Closing the Gaps” initiative of the International Society of Nephrology (ISN), the Global Kidney Health Atlas (ISN-GKHA) has provided an overview of the current state of kidney care and how it is organized and structured across the world, focusing on existing kidney care (AKI, CKD) awareness levels (captured based on existence of relevant policies and guidelines), care structures, and workforce for optimal care delivery. ^, ^, Three iterations of the project have so far been completed in the years 2017, 2019, and 2023. At inception, a total of 125 United Nations Member States (encompassing 93% of the world’s population) responded to the survey as described in more detail elsewhere. For comprehensiveness, the elements of the survey were evaluated within the framework of the Health Systems building blocks outlined by the WHO: leadership and governance, health care financing, health workforce, medical products and technologies, information and research, and service delivery. Study respondents across countries included national nephrology society leadership, policy makers, and patient organization representatives, identified by the country and regional nephrology leadership through the ISN.

Infrastructure for Treatment of Acute Kidney Injury and Chronic Kidney Disease

The ISN-GKHA is the first initiative to assess global capacity for kidney care in terms of the key building blocks of a functional health system and to evaluate the readiness of countries and regions to enhance such care. There were significant gaps in services, workforce, and capacity for research in some countries and regions. For example, most countries in Africa had no facilities for peritoneal dialysis (PD) or kidney transplantation (KT). Few countries had public funding for KRT services and medications for CKD care (including dialysis and transplant); there was a large private (out-of-pocket) contribution toward payment for KRT services and medications, particularly in countries across Africa, South Asia, Oceania, and Southeast Asia. More than two-thirds of countries reported the absence of capacity to participate in clinical research. The noted deficits in infrastructures for kidney care have shown variability with each iteration. The first iteration reported in 2017 showed that globally, 95%, 76%, and 75% of countries had facilities for hemodialysis (HD), peritoneal dialysis (PD), and KT. Although in 2019, the second iteration showed 100%, 76%, and 74% of countries had HD, PD, and KT, respectively, LICs and LMICs had much lower availability of these important services. The third iteration, reported in 2023, using a similar survey instrument showed massive gaps in availability and access to all forms of KRT services between high-income and lower-income countries.

Availability of Chronic Kidney Disease Monitoring and Management Services

There was wide variation in terms of availability of services for CKD monitoring and management at the primary and secondary/tertiary care levels across countries based on income groups ( Fig. 73.14 ). LMIC, especially in Africa, had limited services for the diagnosis, management, and monitoring of CKD at the primary care level, with only 12% having serum creatinine measurement including eGFR. Twenty-nine percent of LIC had access to qualitative urinalysis using urine test strips; however, no LIC had access to urine albumin–to-creatinine ratio (UACR) or urine protein–to-creatinine ratio (UPCR) measurements at the primary care level. Across all income groups, availability of services at the secondary/tertiary care level was considerably higher compared with the primary care level.

Two radar charts show healthcare service availability for chronic kidney disease across World Bank income groups at primary and secondary or tertiary care levels using four color-coded lines. The figure includes two radar charts. The left chart is labeled primary care level, and the right chart is labeled secondary or tertiary care level. Both charts are surrounded by twelve equally spaced radial axes labeled clockwise from the top as blood pressure, height and weight, serum glucose, H B A 1 c, serum cholesterol, creatinine without estimated glomerular filtration rate, creatinine and estimated glomerular filtration rate, urinalysis qualitative, urinalysis quantitative, urine albumin to creatinine ratio or urine protein to creatinine ratio, radiology service, and pathology service. Each chart displays four lines representing income groups as low income as a dotted line with filled circles, lower middle income as a dashed line with hollow circles, upper middle income as a dashed line with filled triangles, and high income as a solid line with filled circles. In the primary care level chart, the high income line reaches close to 100 on all services, especially at blood pressure, height and weight, and serum glucose, the upper middle income line varies from around 30 to 90; the lower middle income line remains between about 20 and 60, the low income line is lowest, staying mostly below 40 and close to 0 for urinalysis quantitative, urine albumin to creatinine ratio or urine protein to creatinine ratio, radiology service, and pathology service. In the secondary or tertiary care level chart, all income groups show generally higher levels compared to the primary care level. The high income line remains near or at 100 across all services, the upper middle income line is above 80 for most axes except urinalysis and urine albumin to creatinine ratio or urine protein to creatinine ratio; the lower middle income line ranges between 40 and 80, and the low income line shows the lowest values, with minimal presence near urinalysis, urine albumin to creatinine ratio or urine protein to creatinine ratio, and radiology service. Both charts feature concentric decagonal rings marked from 0 to 100 in increments of 10, representing percentage availability. A color-coded legend appears between the two charts showing line style and marker type for each income group. — Fig. 73.14

Availability of Kidney Replacement Therapy Services

Dialysis

All countries reported having chronic HD services, and more than 90% of countries reported having acute HD. More than 90% of upper-middle and HICs reported having chronic PD services, with 64% and 35% availability in LMIC and LIC, respectively. In comparison, acute PD had the lowest availability across all income groups.

Kidney transplantation

More than 90% of upper-middle and HICs reported having kidney transplant services, with more than 85% of these countries reporting the organ source as a combination of living and/or deceased donors. As expected, LIC had the lowest availability of kidney transplant services, with only 12% reporting availability and live donors as the only source.

Workforce for Care Delivery

Considerable variation was noted in the density of nephrologists across countries ( Fig. 73.15 ). The lowest density (<5 nephrologists per million population) was common in LIC, whereas the highest density (>15 nephrologists per million population) was mainly reported in HIC. Most countries reported nephrologists as primarily responsible for both CKD and AKI care. Primary care physicians (PCPs) had more responsibility for CKD care than AKI care, as 64% of countries reported PCPs primarily responsible for CKD and 35% for AKI. Intensive care specialists were primarily responsible for AKI in 75% of countries, understandable as AKI is an acute condition typically treated in hospital. However, only 45% of LICs reported that intensive care specialists were primarily responsible for AKI, compared with 90% of HICs. This discrepancy may be due to a general shortage of intensive care specialists in LIC. The appropriate number of nephrologists in a country depends on many factors including need, priority, and resources, and as such there is no global standard with respect to nephrologist density. Regardless, the density in LIC suggests a shortage of nephrologists, which is problematic as nephrologists are essential to provide leadership and a lack of nephrologists may result in consequences for policy and practice. Encouragingly, the number of nephrologists and nephropathologists is rising in LIC, in part due to the existence of fellowship programs supported by international nephrology organizations. ^, Importantly, the role of a nephrologist may differ depending on how the health care system is structured. In some regions, kidney disease patients are primarily cared for by PCPs, and as such the need for nephrologists may differ compared with other regions that primarily depend on a nephrologist for managing kidney disease patients.

A world map shows country-level distribution of nephrologists per million population using four color categories and a separate color for countries with no data reported. The world map is colored to show the distribution of nephrologists per million population by country. Countries shaded in red represent fewer than 1.8 nephrologists per million population, including much of sub-Saharan Africa, Afghanistan, Nepal, Cambodia, Papua New Guinea, and parts of Southeast Asia. Countries shaded in different colors represent 1.8 to 11.7 nephrologists per million population and include most of South America, Central America, Eastern Europe, large parts of the Middle East, South and Southeast Asia, and parts of Northern and Central Africa, 11.8 to 24.7 nephrologists per million population and include Argentina, Brazil, Turkey, Saudi Arabia, Ukraine, Japan, and others, 24.8 or more nephrologists per million population, including the United States, Canada, Chile, much of Western Europe, Saudi Arabia, Iran, Japan, and South Korea, regions where data are not reported, including Greenland, several countries in Central Asia, and some parts of Africa and the Caribbean. A legend at the top defines the color categories with labels such as a color for less than 1.8 per million, a color for 1.8 to 11.7, a color for 11.8 to 24.7, a color for 24.8 or more, and a color for data not reported. Map boundary lines delineate study areas and do not necessarily reflect national borders. — Fig. 73.15

The density statistic merely represents the number of nephrologists per million population and provides no indication of the adequacy to meet the needs of the population or quality of care, which depends on volume of patients with kidney disease and workforce support. For the other care providers essential for kidney care, there were variations in distribution (availability and adequacy) across countries. Overall, provider shortages were highest for renal pathologists (86% of countries reported a shortage), vascular access coordinators (81%), and dietitians (78%) and were more common in low-income countries. Fewer countries (35%) reported a shortage of laboratory technicians ( Fig. 73.16 ).

A horizontal bar graph shows reported shortage percentages across nephrology workforce roles, including nephrologists, dietitians, technicians, nurses, and other professionals. The horizontal bar graph displays the overall shortage in the nephrology workforce for various professional roles. The horizontal axis is labeled in percentage and ranges from 0 to 100 in increments of 10. Each bar represents a workforce category, listed vertically from top to bottom as primary care physicians 34 percent, dialysis technicians 60 percent, dialysis nurses 69 percent, transplant coordinators 69 percent, psychologists 67 percent, nurse practitioners 60 percent, vascular access coordinators 81 percent, pharmacists 30 percent, social workers 62 percent, laboratory technicians 35 percent, renal pathologists 86 percent, dietitians 78 percent, and nephrologists 74 percent. All bars are solid colored with the percentage value written at the end of each bar. The horizontal bars extend to their respective percentage values, showing the magnitude of workforce shortages for each role. — Fig. 73.16

Progress in the Organization, Structures, and Processes of Care at the Global Level, Prepandemic and Post Pandemic

Changes in the availability of health technologies for the care of patients with kidney failure

Globally, the number of centers for the provision of HD is reported to have increased by 9.8%, rising from 4.4 per million population (pmp) in 2019 to 4.8 pmp in 2023 ( Fig. 73.17 ). This proportion increased across most regions except the Middle East, where there was a decrease of–13.1% (3.8 pmp in 2019 to 3.3 pmp in 2023). The number of centers providing PD across countries increased overall by 13% (1.4–1.6 pmp). However, there was a noted decrease in the number of PD centers in Eastern and Central Europe (–14.5%), the Middle East (–7.8%), North and East Asia (–34.5%), and Oceania and South East Asia (OSEA) (–31.5%) (see Fig. 73.17 ). Globally, the number of centers providing KT was reported to have increased by 7% (0.43–0.46 pmp). Region-specific trends showed these centers only increased in Western Europe from 0.52 pmp in 2019 to 0.55 pmp in 2023, representing an increase of 5.8%, but evidenced a reduction in other regions, ranging from–0.9% in North and East Asia to–19.5% in the Middle East region (see Fig. 73.17 ).

A grouped bar graph shows the availability of hemodialysis, peritoneal dialysis, and kidney transplant centers per million population in 2019 and 2023 across regions and income groups. The grouped bar graph is divided into three sections labeled H D for hemodialysis, P D for peritoneal dialysis, and K T for kidney transplant. The horizontal axis is labeled availability of K R T centers per million population, ranging from 0 to 25 in the H D section and from 0 to 5 in the P D and K T sections. Each pair of bars represents the years 2019 and 2023, with teal bars for H D, blue for P D, and purple for K T. Along the vertical axis on the left, the data is categorized by International Society of Nephrology regions and World Bank income groups. In the H D section, overall availability increases from 4.4 to 4.8, with a percent change of plus 9.8 percent marked with an asterisk. Africa increases from 0.5 to 0.8, plus 58.8 percent asterisk. Eastern and Central Europe increases from 9.6 to 10.5, plus 10.3 percent asterisk. Latin America increases from 4.6 to 4.7, plus 4.0 percent. The Middle East decreases from 3.3 to 2.8, minus 13.1 percent. Newly Independent States and Russia increase from 3.7 to 4.8, plus 29.0 percent asterisk. North America and the Caribbean increase from 14.8 to 22.2, plus 50.1 percent. North and East Asia increases from 9.6 to 12, plus 25.8 percent. Oceania and South East Asia increase from 5.7 to 7.3, plus 28.9 percent. South Asia increases from 1.6 to 2.0, plus 26.5 percent. Western Europe increases from 6.9 to 7.7, plus 11.0 percent. Low income increases from 0.2 to 0.3, plus 72.2 percent. Lower-middle income increases from 1.3 to 1.7, plus 23.1 percent asterisk. Upper-middle income increases from 4.7 to 5.4, plus 16.3 percent asterisk. High income decreases slightly from 8.6 to 8.7, minus 1.3 percent. In the P D section, overall availability increases from 1.4 to 1.6, plus 13.0 percent. Africa increases from 0.1 to 0.2, plus 44.4 percent. Eastern and Central Europe decreases from 2 to 1.7, minus 14.5 percent. Latin America increases from 1.1 to 1.8, plus 55.8 percent. The Middle East decreases from 0.7 to 0.8, minus 7.8 percent. Newly Independent States and Russia increase from 0.4 to 0.6, plus 48.8 percent asterisk. North America and the Caribbean increase from 1.7 to 3.6, plus 115.8 percent asterisk. North and East Asia decreases from 1.3 to 1.9, minus 34.5 percent. Oceania and South East Asia decreases from 1.5 to 2.2, minus 31.55 percent. South Asia remains at 0.1, plus 7.7 percent. Western Europe increases from 2.4 to 2.7, plus 12.9 percent. Low income decreases from 0.1 to 0.1, minus 33.3 percent. Lower-middle income increases from 0.2 to 0.3, plus 29.4 percent. Upper-middle income increases from 0.8 to 1.1, plus 27.4 percent. High income increases from 2.3 to 2.5, plus 6.4 percent. In the K T section, overall availability increases from 0.4 to 0.5, plus 7 percent. Africa remains at 0.2, minus 6.7 percent. Eastern and Central Europe decreases from 0.7 to 0.7, minus 1.4 percent. Latin America decreases from 0.5 to 0.4, minus 4.2 percent. Middle East decreases from 0.3 to 0.4, minus 19.5 percent. Newly Independent States and Russia decreases from 0.3 to 0.3, minus 3.0 percent. North America and the Caribbean decreases from 0.7 to 0.8, minus 5.3 percent. North and East Asia decreases from 1.1 to 1.1, minus 0.9 percent. Oceania and South East Asia decreases from 0.4 to 0.4, minus 17.1 percent. South Asia remains at 0.1, minus 15.4 percent. Western Europe increases from 0.5 to 0.6, plus 5.8 percent. Low income decreases from 0.2 to 0.2, minus 6.3 percent. Lower-middle income increases from 0.2 to 0.2, plus 11.1 percent. Upper-middle income increases from 0.4 to 0.4, plus 5.1 percent. High income remains at 0.6. A vertical line separates each section, and percent changes are labeled next to the 2023 bars. Statistically significant changes are marked with an asterisk. A legend at the top center indicates bar colors as teal for H D, blue for P D, and purple for K T, with year labels 2019 and 2023 shown in white text inside the bars. All values represent availability per million population. — Fig. 73.17

Changes in quality of kidney replacement therapy and availability of routine diagnostic and management of complications associated with kidney failure

Overall, the proportion of countries where HD was offered thrice weekly (3 to 4 hours per session) increased by 7.8% ( Fig. 73.18 ). This proportion increased in Africa (25.6%), Latin America (12.4%), Newly Independent States (NIS) and Russia (16.3%), North America and the Caribbean (75.4%), and South Asia (32.6%) (see Fig. 73.18 ). Overall, the proportion of countries where adequate PD (defined as three to four exchanges per day or equivalent cycles on automated PD) was offered increased by 1.7%. World regions with the highest percentage increase for adequate PD were North America and the Caribbean (65.1%), Latin America (23.9%), and Africa (21.4%). Overall, countries with capacity for provision of facilities for management of kidney transplant (defined as provision of appropriate immunosuppression and antirejection treatments) did not change and only increased in Latin America (13.3%), North America and the Caribbean (24.6%), and the North and East Asia region (20.5%) (see Fig. 73.18 ).

A radial bar graph of the percentage change from 2019-2023 in the quality of kidney replacement therapy by region for hemodialysis, peritoneal dialysis, and kidney transplant, with color-coded bars. The radial bar graph displays percentage values extending outward from the center, with concentric rings marking intervals from 0 to 100 percent in steps of 10. Twelve regions are arranged around the circle in clockwise order: overall at the top center, Africa, Eastern and Central Europe, Latin America, the Middle East, Newly Independent States and Russia, North America and the Caribbean, North and East Asia, Oceania and South East Asia, South Asia, and Western Europe. Each region includes three pairs of bars for the years 2019 and 2023, color-coded for hemodialysis, peritoneal dialysis, and kidney transplant. Bars for 2019 are darker, and bars for 2023 are lighter. In the overall category, the hemodialysis bar increases from 77 to 83 percent, peritoneal dialysis from 61 to 62 percent, and kidney transplant from 60 to 73 percent, with a net percentage change of plus 7.8 percent. In Africa, hemodialysis increases from 43 to 54 percent, peritoneal dialysis from 26 to 43 percent, and kidney transplant from 25 to 43 percent, with a percentage change of plus 25.6 percent. In Eastern and Central Europe, hemodialysis drops from 69 to 48 percent, peritoneal dialysis from 43 to 43 percent, and kidney transplant from 69 to 69 percent, with a change of minus 31 percent marked with an asterisk. In Latin America, hemodialysis increases from 67 to 75 percent, peritoneal dialysis from 67 to 83 percent, and kidney transplant from 83 to 94 percent, with a net change of plus 12.4 percent. In the Middle East, hemodialysis rises from 73 to 83 percent, peritoneal dialysis from 91 to 94 percent, and kidney transplant from 91 to 91 percent, with a net change of plus 14.1 percent. In the Newly Independent States and Russia, hemodialysis increases from 43 to 71 percent, peritoneal dialysis from 43 to 43 percent, and kidney transplant from 86 to 86 percent, with a change of minus 14 percent. In North America and the Caribbean, hemodialysis increases from 43 to 71 percent, peritoneal dialysis from 57 to 83 percent, and kidney transplant from 57 to 83 percent, with a change of plus 75.4 percent. In North and East Asia, hemodialysis increases from 57 to 83 percent, peritoneal dialysis from 71 to 71 percent, and kidney transplant from 71 to 71 percent, with a net change of plus 24.6 percent. In Oceania and South East Asia, hemodialysis decreases from 87 to 80 percent, peritoneal dialysis from 83 to 83 percent, and kidney transplant from 83 to 83 percent, with a change of minus 8.1 percent. In South Asia, hemodialysis increases from 57 to 71 percent, peritoneal dialysis from 43 to 57 percent, and kidney transplant from 43 to 57 percent, with a change of plus 32.6 percent. In Western Europe, hemodialysis decreases from 95 to 90 percent, peritoneal dialysis from 95 to 95 percent, and kidney transplant from 95 to 95 percent, with a change of minus 5 percent. A legend in the upper right shows different color bars for hemodialysis, peritoneal dialysis, and kidney transplant, with dark shades for 2019 and lighter shades for 2023. An asterisk next to a percentage value indicates statistical significance with a p-value less than 0.05. All values represent the percentage of facilities delivering therapy at adequate frequency or quality. — Fig. 73.18

Changes in access to kidney replacement therapy

Globally, the change in the proportion of patients with access to KRT modalities, HD, PD, and KT were 2.8%, 50%, and–3.3% across both periods ( Fig. 73.19 ). Countries where >50% of kidney failure patients can access HD remained the same in North America and Caribbean, OSEA, and the Western Europe region but increased in Africa (17.7%), Eastern and Central Europe (6.4%), the Middle East (22%), and North and East Asia (20.5%). Although there was a global reduction in the proportion of countries where >50% of kidney failure patients can access KT, there was an increase in Africa (100%), Latin America (29.4%), and Western Europe (41.7%). Only HICs reported an increase in proportion of countries with access to KT (1.8%); this proportion reduced in LMICs (–72.7%) and remained the same in LICs and UMICs (see Fig. 73.19 ).

A grouped horizontal bar graph of accessibility to hemodialysis, peritoneal dialysis, and kidney transplant by region and income level in 2019 and 2023, with percentage change and color-coded bars. The horizontal bar graph is divided into three sections for hemodialysis, peritoneal dialysis, and kidney transplant. Each section contains grouped bars for 2019 and 2023. Bars for 2019 are represented in darker shades for hemodialysis, peritoneal dialysis, and kidney transplant. Bars for 2023 are in lighter shades for hemodialysis, peritoneal dialysis, and kidney transplant. The horizontal axis is labeled accessibility to kidney replacement therapy per million population and ranges from 0 to 100. Under hemodialysis, the overall value increases from 72 to 74 with a percent change of plus 2.8. Africa increases from 34 to 40, plus 17.7. Eastern and Central Europe increases from 94 to 100, plus 6.4. Latin America decreases from 89 to 94, minus 5.3. The Middle East increases from 82 to 100, plus 22.0. Newly Independent States and Russia decrease from 71 to 86, minus 17.4. North America and the Caribbean remain at 86. North and East Asia increases from 83 to 100, plus 20.5. Oceania and South East Asia remain at 67. South Asia increases from 0 to 17. Western Europe remains at 100. Low-income group increases from 13 to 31, plus 138.5. Lower-middle income decreases from 42 to 47, minus 10.6. Upper-middle income increases from 82 to 85, plus 3.7. High income increases from 98 to 100, plus 2.0. Under peritoneal dialysis, overall increases from 4 to 6, plus 50. Africa remains at 6. Eastern and Central Europe remains at 6. Latin America decreases from 11 to 6, minus 45.5. The Middle East remains at 0. Newly Independent States and Russia increase from 0 to 20. North America and the Caribbean remain at 0. North and East Asia increase from 0 to 17. Oceania and South East Asia increase from 0 to 7. South Asia remains at 0. Western Europe increases from 0 to 10. Low income remains at 0. Lower-middle income increases from 0 to 6. Upper-middle income increases from 3 to 9, plus 50. High income increases from 6 to 9, plus 50. Under kidney transplant, overall decreases from 30 to 29, minus 3.3. Africa increases from 3 to 6, plus 100. Eastern and Central Europe increases from 17 to 22, plus 29.4. Latin America remains at 36. The Middle East decreases from 73 to 36, minus 50.7, marked with an asterisk. Newly Independent States and Russia decrease from 43 to 14, minus 67.4. North America and the Caribbean decrease from 29 to 14, minus 51.7. North and East Asia remain at 17. Oceania and South East Asia decrease from 27 to 13, minus 51.9. South Asia remains at 0. Western Europe increases from 60 to 85, plus 41.7. Low income remains at 6. Lower-middle income decreases from 11 to 3, minus 72.7. Upper-middle income increases from 6 to 9, plus 50. High income increases from 55 to 56, plus 1.8. Each bar pair is followed by a percentage change value written in bold. Statistically significant values are marked with an asterisk. A legend in the top right indicates different colors used for hemodialysis, peritoneal dialysis, and kidney transplant. Labels on the left margin identify International Society of Nephrology regions and World Bank income groups in the following order from top to bottom as overall, Africa, Eastern and Central Europe, Latin America, Middle East, Newly Independent States and Russia, North America and the Caribbean, North and East Asia, Oceania and South East Asia, South Asia, Western Europe, low income, lower-middle income, upper-middle income, and high income. All values represent accessibility to kidney replacement therapy per million population.

Tags: Boris Bikbov; Aminu K. Bello; Gloria Enow Ashuntantang-Some, Valerie A. Luyckx

May 3, 2026 | Posted by drzezo in NEPHROLOGY | Comments Off

Abdominal Key

Fastest Abdominal Insight Engine

Global Challenges and Progress in Kidney Health

Key Points

Global Challenges in Kidney Health

Kidney Disease is an Important Public Health Concern