World Journal of Nephrology and Urology, ISSN 1927-1239 print, 1927-1247 online, Open Access
Article copyright, the authors; Journal compilation copyright, World J Nephrol Urol and Elmer Press Inc
Journal website https://www.wjnu.org

Review

Volume 13, Number 1, July 2024, pages 1-12

Mind the Gap in Kidney Care: Translating What We Know Into What We Do

Figures

Figure 1.
Figure 1. All ages, top 10 global risk factors for death, 2019. Kidney dysfunction (defined as estimated glomerular filtration rate < 60 mL/min/1.73 m2 or albumin-to-creatinine ratio ≥ 30 mg/g) was the seventh leading global level 3 risk factor for death in 2019. The three leading global risk factors for kidney disease, including hypertension, diabetes, and overweight/obesity, are also leading global risk factors for death; therefore, holistic strategies are required to address all risk factors simultaneously. Ranking is depicted by millions if deaths are attributed to the risk factors. Error bars depict the confidence range. Global ranking of kidney dysfunction stratified by World Bank income category and gender is shown in Supplementary Material 1 (www.wjnu.org). Data obtained from the Global Burden of Disease Study [2]. BMI: body mass index; LDL: low-density lipoprotein.
Figure 2.
Figure 2. Proportion of people with chronic kidney disease (CKD) who are aware of their diagnosis and are receiving appropriate guideline-recommended care. The proportion of people with CKD who are aware of their diagnosis varies globally, with rates ranging from 7% to 20%. As CKD stage worsens, knowledge of CKD increases. Among those with a diagnosis of CKD, the average proportion of patients receiving appropriate medication to delay CKD progression (renin-angiotensin-aldosterone system (RAS) inhibitors and sodium-glucose cotransporter 2 (SGLT2) inhibitors) is suboptimal as are those reaching target blood pressure, diabetes control, and nutrition advice. The treatment targets depicted in the figure follow the Kidney Disease: Improving Global Outcomes (KDIGO) 2012 guidelines [15]. Most data come from higher-resource settings; these proportions are likely lower in lower-resource settings. Data are shown for proportions of patients reaching blood pressure of < 130/80 mm Hg. Data compiled from previous studies [15-20]. HbA1c: hemoglobin A1c.
Figure 3.
Figure 3. Recommended optimal lifestyle and therapeutic management for chronic kidney disease (CKD) in diabetes. Illustration of a comprehensive and holistic approach to optimizing kidney health in people with CKD. In addition to the cornerstone lifestyle adjustments, attention to diabetes, blood pressure (BP), and cardiovascular risk factor control is intergral to kidney care. *Angiotensin-converting enzyme inhibitor or angiotensin II receptor blocker should be first-line therapy for BP control when albuminuria is present; otherwise dihydropyridine calcium channel blocker (CCB) or diuretic can also be considered. Figure reproduced from [22]. Copyright © 2023, Kidney Disease: Improving Global Outcomes (KDIGO). Published by Elsevier Inc. on behalf of the International Society of Nephrology under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). ASCVD: atherosclerotic cardiovascular disease; CKD-MBD: chronic kidney disease-mineral and bone disorder; eGFR: estimated glomerular filtration rate; GLP-1 RA: glucagon-like peptide-1 receptor agonist; HTN: hypertension; MRA: mineralocorticoid receptor antagonist; ns-MRA: nonsteroidal mineralocorticoid receptor antagonist; PCSK9i: proprotein convertase subtilisin/kexin type 9 inhibitor; RAS: renin-angiotensin-aldosterone system; SBP: systolic blood pressure; SGLT2i: sodium-glucose cotransporter 2 inhibitor.
Figure 4.
Figure 4. Depiction of the spectrum of factors impacting implementation of timely and quality kidney care. CKD: chronic kidney disease; NCD: noncommunicable disease; UHC: universal health coverage.

Tables

Table 1. Essential Medicines for Patients With Kidney Disease
 
Medication/technologyExampleReasonOn WHO model list of essential medicines
aPolypills containing aspirin may not be appropriate for patients with early CKD without other cardiovascular indications. ACE: angiotensin-converting enzyme; BP: blood pressure; CAD: coronary artery disease; CKD: chronic kidney disease; DM: diabetes mellitus; GFR: glomerular filtration rate; GLP1: glucagon-like peptide-1; MI: myocardial infarction; SGLT2: sodium-glucose cotransporter 2; WHO: World Health Organization.
ACE inhibitorEnalapril, lisinoprilDelays CKD progression, benefits cardiovascular disease and strokeYes
Angiotensin receptor blockerLosartan, telmisartanDelays CKD progression, cardiovascular disease, and strokeYes
Calcium channel blockerAmlodipine, verapamilBlood pressure controlYes
Loop diureticsFurosemide, torsemideGood when GFR is low, good for heart failureYes
Thiazide diureticsHydrochlorothiazide, metolazone, indapamideGood for BP, especially in the Black populationYes
SGLT2 inhibitorEmpagliflozin, canagliflozin, dapagliflozinDiabetes control, delays CKD progression, cardiovascular disease, and deathYes
GLP1 agonistSemaglutideDiabetes control, weight lossNo
Mineralocorticoid inhibitorSpironolactone, finerenoneDelays CKD progression, reduces heart failure risk
Caution: risk of hyperkalemia in patients with kidney disease		Yes/no
β-BlockerBisoprololPrevention and treatment of ischemic heart diseaseYes
StatinsSimvastatinPrevention of CAD in patients with CKD, transplantYes
AspirinSecondary prevention of MI in patients with CKD, transplantYes
Fixed-dose combinations (polypill)aAspirin + atorvastatin + ramiprilSimultaneous management of CKD and cardiovascular disease and risk factors where indicatedaYes
Aspirin + simvastatin + ramipril + atenolol + hydrochlorthiazideYes
Aspirin + perindopril + amlodipineYes
Oral hypoglycemic medicationGliclazide, metformin, SGLT2 inhibitorsDM management
Caution with dosing and glomerular filtration rate		Yes
InsulinLong and short actingDM managementYes

 

Table 2. Examples of Strategies to Improve Implementation of Appropriate CKD Care
 
DomainPotential solutions
CKD: chronic kidney disease; NCD: noncommunicable disease; SDG: sustainable development goal; UHC: universal health coverage.
Health policyInclude NCD and CKD as health care priorities; ensure sustainable financing; monitor disease burdens and outcomes; registries; multisectoral action; promote kidney health through public health measures; achieve SDGs
Health systemsIntegrate CKD care into primary care under UHC; establish quality standards; include necessary diagnostics and medications in national essential medication/diagnostic lists; monitoring and evaluation; reduce brain drain; monitor equity; simplify and streamline guidelines
Quality assuranceRegulation and monitoring of medication quality, especially of generics. Monitoring of health outcomes and care processes to permit iterative improvement
Health care professionalsReduce time pressure; improve knowledge; broaden scope of practice (e.g., pharmacists); engage community health workers
Patient empowermentHealth literacy; education; community engagement; involvement in research design and conduct
Medication costQuality generics; reduce prices; UHC for essential medications
Implementation researchIdentify barriers within local contexts; test solutions to overcome barriers
PolypillsReduce cost; lower pill burden
Digital technologiesElectronic pill boxes, bags, bottles; blister pack technology; ingestible sensors; electronic medication management systems; patient self-report technology; video-based technology; motion sensor technology; telemedicine; smartphone apps; electronic health records