The global burden of kidney disease and the sustainable development goals

The 17 sustainable development goals (SDGs) were adopted by the United Nations, as successors to the millennium development goals, with the broad goal of achieving healthy people living on a healthy planet. Although only SDG 3, that is, to ensure healthy lives and promote well-being for all at all ages, is specifically focused on health, achievement of all of the SDGs should have health benefits via impacts on the environment, governance and society.

The Global action plan for the prevention and control of noncommunicable diseases 2013–2020 (hereafter called the 2013 action plan) outlined an approach to reduce the combined mortality from four major categories of noncommunicable disease, i.e. cancer, cardiovascular disease, chronic respiratory disease and diabetes, by 25% by 2025.

Previously, these four categories had been prioritized in the 2008–2013 action plan because, collectively, they were believed to account for about 60% of global deaths and it was anticipated that a large proportion of these deaths could be prevented through elimination of shared risk factors, e.g. alcohol and tobacco use, poor diets and inadequate exercise.

Although laudable, the 2013 action plan has been criticized for failing to acknowledge the broader drivers of the noncommunicable disease epidemics, other important noncommunicable diseases and the so-called causes of the causes of noncommunicable diseases and failing to place sufficient emphasis on the need for coordinated multisectoral action.

We argue that kidney disease represents one of the important noncommunicable diseases missing from the 2013 action plan and that, given the many social and structural factors that directly affect risks and outcomes of kidney disease, multisectoral action to achieve the SDGs will help prevent and control such disease.

Global burden

Although often considered a comorbidity of diabetes or hypertension, kidney disease has numerous complex causes.5 Importantly, such disease has an indirect impact on global morbidity and mortality by increasing the risks associated with at least five other major killers: cardiovascular diseases, diabetes, hypertension, infection with human immunodeficiency virus (HIV) and malaria.

For example, the Global Burden of Disease (GBD) 2015 study estimated that 1.2 million deaths, 19 million disability-adjusted life-years (DALYs) and 18 million years of life lost from cardiovascular diseases were directly attributable to reduced glomerular filtration rates.

The GBD 2015 study also estimated that, in 2015, 1.2 million people died from kidney failure, an increase of 32% since 2005. In 2010, an estimated 2.3–7.1 million people with end-stage kidney disease died without access to chronic dialysis. Additionally, each year, around 1.7 million people are thought to die from acute kidney injury. Overall, therefore, an estimated 5–10 million people die annually from kidney disease.

Given the limited epidemiological data, the common lack of awareness and the frequently poor access to laboratory services, such numbers probably underestimate the true burden posed by kidney disease. It is therefore possible that, each year, at least as many deaths are attributable to kidney disease as to cancer, diabetes or respiratory diseases, three of the four main categories targeted by the 2013 action plan.

In addition, the estimated number of DALYS attributable to kidney disease globally increased from 19 million in 1990 to 33 million in 2013. In 2016, the DALYs associated with chronic kidney disease, along with those associated with cardiovascular disease, cancers, diabetes and neurological disorders, were found to have increased significantly between 1990 and 2015.

A report from the GBD 2016 study highlighted the important omission of focus on chronic kidney disease and suggested that “the SDG agenda offers at best a minimal platform for drawing attention to the health care and monitoring needs of [chronic kidney disease].”

Kidney disease is associated with a tremendous economic burden. High-income countries typically spend more than 2–3% of their annual health-care budget on the treatment of end-stage kidney disease, even though those receiving such treatment represent under 0.03% of the total population. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was projected to double by 2030.

Globally, the total cost of the treatment of the milder forms of chronic kidney disease appears to be much greater than the total cost of treating end-stage kidney disease. In 2015, in the United States of America, for example, Medicare expenditures on chronic and end-stage kidney disease were more than 64 billion and 34 billion United States dollars, respectively.

Much of the expenditure, morbidity and mortality previously attributed to diabetes and hypertension are attributable to kidney disease and its complications.

Worldwide, important risk factors for kidney disease include diarrhoeal diseases, HIV infection, low birth weight, malaria and preterm birth, all of which are also leading global causes of DALYs. Risks of kidney disease span the life-course and environmental, infection and lifestyle etiologies.

 If risk factors are identified early, acute kidney injury and chronic kidney disease can be prevented and, if kidney disease is diagnosed early, worsening of kidney function can be slowed or averted by inexpensive interventions, several of which are on the World Health Organization’s (WHO’s) so-called best buys list for noncommunicable disease management.

Such interventions include counselling for cardiovascular disease, diabetes and hypertension, drug therapy, tobacco control, promotion of physical activity and the reduction of salt intake through legislation and food labelling.

The timely identification and management of acute kidney injury and chronic kidney disease represent the most effective strategy to address the growing global burden sustainably. By advocating for a multisectoral approach, as a means to achieving the SDGs, it should be possible to reduce the incidence of kidney disease globally. We discuss the kidney-health-related opportunities offered by attempts to achieve each SDG.

Policy perspective

The net health burden of kidney disease is substantial, growing and driven by complex interactions, between communicable and noncommunicable diseases, that are shaped by upstream environmental and socioeconomic disparities.

Although kidney disease, whether acute, chronic or end-stage, can be extremely costly, it is also potentially preventable and adverse outcomes can often be delayed or prevented by inexpensive interventions.

Kidney disease is highly prevalent, spans the life course and has substantial financial implications. Our response to such disease requires a systematic policy approach, to strengthen all relevant aspects of the health system and to facilitate integration of the promotion of kidney health within a comprehensive horizontal programme for the prevention and treatment of noncommunicable diseases.

Within each country, the local burden and prevalence of kidney disease and its risk factors and the local capacity to identify and manage such disease must be determined, as a prerequisite for fair priority setting and appropriate policy development. Diagnosis of kidney disease is often hampered by a lack of awareness among health-care workers and at-risk communities and by inadequate and often erratic access to laboratory testing.

Broad policies are increasingly being adopted globally to curb dietary intakes of fat, salt and sugar. Such policies all promise to reduce the burden of chronic kidney disease. The burden of acute kidney injury could be reduced through the ongoing commitment to reduce the transmission of the pathogens causing infectious diseases.

We need universal health coverage to tackle kidney disease successfully and ensure effective screening, prevention and early treatment. Effective and transparent policies to govern access to care for end-stage kidney disease should only be developed after there has been a thorough attempt to determine the local health priorities, especially in resource-poor settings.

Engagement with all relevant stakeholders and innovative financing strategies will be required to maximize equitable access to care. The bidirectional and synergistic interplay between kidney disease and all of the SGDs must be acknowledged in the development of a multisectoral approach.

Policies that foster domestic and international collaboration, improve occupational and road safety, limit organ trafficking, promote access to education and gender equality, reduce unemployment and tackle the predicted adverse effects of climate change may all reduce kidney disease and/or the disparities in the care for such disease.

However, as noted by the United Nations Secretary-General in December 2017, in the control and prevention of noncommunicable diseases, “political commitments have not often been translated into concrete action.” On its own, policy-making is insufficient.

Monitoring the impact of policies on kidney disease and the risk factors for such disease needs to be integrated into existing surveillance activities. Health workers and communities must be empowered to advocate for, and hold policy-makers accountable for, kidney health, as an important step towards achievement of the SDGs.

 

The global burden of kidney disease and the sustainable development goals

The 17 sustainable development goals (SDGs) were adopted by the United Nations, as successors to the millennium development goals, with the broad goal of achieving healthy people living on a healthy planet. Although only SDG 3, that is, to ensure healthy lives and promote well-being for all at all ages, is specifically focused on health, achievement of all of the SDGs should have health benefits via impacts on the environment, governance and society. The Global action plan for the prevention and control of noncommunicable diseases 20132020 (hereafter called the 2013 action plan) outlined an approach to reduce the combined mortality from four major categories of noncommunicable disease, i.e. cancer, cardiovascular disease, chronic respiratory disease and diabetes, by 25% by 2025. Previously, these four categories had been prioritized in the 20082013 action plan because, collectively, they were believed to account for about 60% of global deaths and it was anticipated that a large proportion of these deaths could be prevented through elimination of shared risk factors, e.g. alcohol and tobacco use, poor diets and inadequate exercise. Although laudable, the 2013 action plan has been criticized for failing to acknowledge the broader drivers of the noncommunicable disease epidemics, other important noncommunicable diseases and the so-called causes of the causes of noncommunicable diseases and failing to place sufficient emphasis on the need for coordinated multisectoral action. We argue that kidney disease represents one of the important noncommunicable diseases missing from the 2013 action plan and that, given the many social and structural factors that directly affect risks and outcomes of kidney disease, multisectoral action to achieve the SDGs will help prevent and control such disease. Global burden Although often considered a comorbidity of diabetes or hypertension, kidney disease has numerous complex causes.5 Importantly, such disease has an indirect impact on global morbidity and mortality by increasing the risks associated with at least five other major killers: cardiovascular diseases, diabetes, hypertension, infection with human immunodeficiency virus (HIV) and malaria. For example, the Global Burden of Disease (GBD) 2015 study estimated that 1.2 million deaths, 19 million disability-adjusted life-years (DALYs) and 18 million years of life lost from cardiovascular diseases were directly attributable to reduced glomerular filtration rates. The GBD 2015 study also estimated that, in 2015, 1.2 million people died from kidney failure, an increase of 32% since 2005. In 2010, an estimated 2.37.1 million people with end-stage kidney disease died without access to chronic dialysis. Additionally, each year, around 1.7 million people are thought to die from acute kidney injury. Overall, therefore, an estimated 510 million people die annually from kidney disease. Given the limited epidemiological data, the common lack of awareness and the frequently poor access to laboratory services, such numbers probably underestimate the true burden posed by kidney disease. It is therefore possible that, each year, at least as many deaths are attributable to kidney disease as to cancer, diabetes or respiratory diseases, three of the four main categories targeted by the 2013 action plan. In addition, the estimated number of DALYS attributable to kidney disease globally increased from 19 million in 1990 to 33 million in 2013. In 2016, the DALYs associated with chronic kidney disease, along with those associated with cardiovascular disease, cancers, diabetes and neurological disorders, were found to have increased significantly between 1990 and 2015. A report from the GBD 2016 study highlighted the important omission of focus on chronic kidney disease and suggested that the SDG agenda offers at best a minimal platform for drawing attention to the health care and monitoring needs of [chronic kidney disease]. Kidney disease is associated with a tremendous economic burden. High-income countries typically spend more than 23% of their annual health-care budget on the treatment of end-stage kidney disease, even though those receiving such treatment represent under 0.03% of the total population. In 2010, 2.62 million people received dialysis worldwide and the need for dialysis was projected to double by 2030. Globally, the total cost of the treatment of the milder forms of chronic kidney disease appears to be much greater than the total cost of treating end-stage kidney disease. In 2015, in the United States of America, for example, Medicare expenditures on chronic and end-stage kidney disease were more than 64 billion and 34 billion United States dollars, respectively. Much of the expenditure, morbidity and mortality previously attributed to diabetes and hypertension are attributable to kidney disease and its complications. Worldwide, important risk factors for kidney disease include diarrhoeal diseases, HIV infection, low birth weight, malaria and preterm birth, all of which are also leading global causes of DALYs. Risks of kidney disease span the life-course and environmental, infection and lifestyle etiologies. If risk factors are identified early, acute kidney injury and chronic kidney disease can be prevented and, if kidney disease is diagnosed early, worsening of kidney function can be slowed or averted by inexpensive interventions, several of which are on the World Health Organizations (WHOs) so-called best buys list for noncommunicable disease management. Such interventions include counselling for cardiovascular disease, diabetes and hypertension, drug therapy, tobacco control, promotion of physical activity and the reduction of salt intake through legislation and food labelling. The timely identification and management of acute kidney injury and chronic kidney disease represent the most effective strategy to address the growing global burden sustainably. By advocating for a multisectoral approach, as a means to achieving the SDGs, it should be possible to reduce the incidence of kidney disease globally. We discuss the kidney-health-related opportunities offered by attempts to achieve each SDG. Policy perspective The net health burden of kidney disease is substantial, growing and driven by complex interactions, between communicable and noncommunicable diseases, that are shaped by upstream environmental and socioeconomic disparities. Although kidney disease, whether acute, chronic or end-stage, can be extremely costly, it is also potentially preventable and adverse outcomes can often be delayed or prevented by inexpensive interventions. Kidney disease is highly prevalent, spans the life course and has substantial financial implications. Our response to such disease requires a systematic policy approach, to strengthen all relevant aspects of the health system and to facilitate integration of the promotion of kidney health within a comprehensive horizontal programme for the prevention and treatment of noncommunicable diseases. Within each country, the local burden and prevalence of kidney disease and its risk factors and the local capacity to identify and manage such disease must be determined, as a prerequisite for fair priority setting and appropriate policy development. Diagnosis of kidney disease is often hampered by a lack of awareness among health-care workers and at-risk communities and by inadequate and often erratic access to laboratory testing. Broad policies are increasingly being adopted globally to curb dietary intakes of fat, salt and sugar. Such policies all promise to reduce the burden of chronic kidney disease. The burden of acute kidney injury could be reduced through the ongoing commitment to reduce the transmission of the pathogens causing infectious diseases. We need universal health coverage to tackle kidney disease successfully and ensure effective screening, prevention and early treatment. Effective and transparent policies to govern access to care for end-stage kidney disease should only be developed after there has been a thorough attempt to determine the local health priorities, especially in resource-poor settings. Engagement with all relevant stakeholders and innovative financing strategies will be required to maximize equitable access to care. The bidirectional and synergistic interplay between kidney disease and all of the SGDs must be acknowledged in the development of a multisectoral approach. Policies that foster domestic and international collaboration, improve occupational and road safety, limit organ trafficking, promote access to education and gender equality, reduce unemployment and tackle the predicted adverse effects of climate change may all reduce kidney disease and/or the disparities in the care for such disease. However, as noted by the United Nations Secretary-General in December 2017, in the control and prevention of noncommunicable diseases, political commitments have not often been translated into concrete action. On its own, policy-making is insufficient. Monitoring the impact of policies on kidney disease and the risk factors for such disease needs to be integrated into existing surveillance activities. Health workers and communities must be empowered to advocate for, and hold policy-makers accountable for, kidney health, as an important step towards achievement of the SDGs.