Prevalence of CKD is high, yet level of care remains low

Prevalence of CKD is high, yet level of care remains low

Did you know that globally, patients living with chronic kidney disease (CKD) surpass twice the population of those affected by diabetes and exceed over twenty-fold the number affected by human immunodeficiency virus/acquired immune deficiency syndrome?1

The prevalence of CKD in Africa is estimated to be around ~4.2% (~50 million), compared to the global prevalence of ~9.5% (~760 million). This is according to a new report published by the International Society of Nephrology and the Global Kidney Health Atlas.2

The prevalence of CKD in South Africa ranges from 6.4% to 8.7%. This means that between 3.8 million and four million South Africans have CKD. Women (12.1%) have a higher risk of CKD compared to men (8.1%).1

The number of disability-adjusted life years (DALYs) attributable to CKD is 491.4 per 100 000 population. The median proportion of deaths attributable to CKD is 2.4%.2

The report, published in the March issue of the Lancet, also assessed the availability, accessibility, quality, and affordability of medicines, kidney replacement therapy (KRT), and conservative kidney management (CKM, defined as planned, holistic, patient-centred care that did not include KRT for people living with stage 5 CKD [see Table 1]).2

Kidney Disease: Improving Global Outcomes (KDIGO) defines CKD as abnormalities of kidney structure or function, present for >3 months, with implications for health and CKD is classified based on cause, glomerular filtration rate (GFR) category (see Table 1), and albuminuria category (see Table 2).3

Risk factors for CKD include diabetes, hypertension, obesity, smoking, and a familial predisposition to kidney disease. Hypertension and diabetes are the main causes of CKD:2,4

• Type 2 diabetes: 30% to 50%

• Type 1 diabetes: 3.9%

• Hypertension: (27.2%). Furthermore, factors such as obesity and smoking have also been linked to an increased risk of developing CKD.2

Availability, accessibility, quality, and affordability

The report alluded to above, revealed significant variations in health spending, workforce, and infrastructure. The median total health spending for CKD treatment was R6700 ($353) per capita, with a median government health spending of R4081 ($216) per capita and a median out-ofpocket health spending of R1738 ($92) per capita. Health spending increased with country income level.2

For in-centre haemodialysis, the annual median cost ranged from R32 000 ($1646) in Burkina Faso to R1.9m ($103 443) in Costa Rica. Similarly, peritoneal dialysis (median R358 213 [$18 959]) and kidney transplantation (median R508 307 [$26 903]) costs also demonstrated considerable variation.2

The health workforce varied widely, with overall densities per 1000 population of 36.2 nurses, 17.7 medical doctors, and 1.9 specialist physicians. Regional and incomelevel disparities were evident.2

Regarding KRT delivery, there was significant variability in capacity across countries. Home haemodialysis services were provided in high-income countries (HICs), and the availability of services like peritoneal dialysis and kidney transplantation varied across regions.2

Dialysis accessibility for those with kidney failure showed disparities by country income level, with HICs having higher accessibility rates. CKM was available in 53% of countries, mostly in HICs.2

Infrastructure for patient support and shared decision-making was present in >50% of countries. Essential medicines for pain and palliative care were available in 59% of countries, with disparities in infrastructure across regions.2

Public funding for chronic haemodialysis varied, with 45% of countries providing free services at the point of delivery. Payment methods for KRT varied, with private and out-of-pocket payments reported in some countries, particularly in Africa.2

The nephrology workforce demonstrated significant variations globally, with a median prevalence of 11.8 nephrologists per million population. Shortages of nephrologists, paediatric nephrologists, transplant surgeons, dietitians, and dialysis nurses were reported, particularly in low- and middle-income countries.2

Registries for CKD, dialysis, kidney transplantation, and CKM varied in availability. CKD detection programmes were implemented reactively in many countries, limiting proactive management.2 Leadership and governance structures for CKD management were present in 63% of countries. Only 25% had national CKD-specific strategies, and less than half recognised CKD as a health priority.2

Comparing data from 2019 to 2023 indicated increases in the density of haemodialysis and peritoneal dialysis centres, kidney transplantation centres, and nephrologist prevalence. Changes in public funding and free services for KRT and essential medications were also noted.2

According to the authors of the report, the data underscores the complex landscape of CKD treatment, highlighting the need for targeted interventions and resource allocation to address disparities and improve global kidney care.2

Updated KGIDO guideline

The latest update (2020) KGIDO guideline stresses the importance of optimising patient care and treatment outcomes. To achieve these goals, the organisation recommends:5

• Initiating treatment with angiotensin-converting enzyme inhibitors (ACEi) or angiotensin II receptor blockers (ARB) in patients living with diabetes, hypertension, and albuminuria. The medications should be titrated to the highest approved dose tolerated. For patients with diabetes, albuminuria, and normal blood pressure (BP), consideration of ACEi or ARB is warranted.

• KDIGO recommends the following ACEis: Benazepril, captopril, enalapril, fosinopril, lisinopril, perindopril, quinapril, ramipril, trandolapril. The organisation recommends the following ARBs: Azilsartan, candesartan, irbesartan, losartan, olmesartan, telmisartan, valsartan.

• Continuous monitoring of BP, serum creatinine, and serum potassium within two to four weeks of initiation or dose increase is emphasised. ACEi or ARB therapy should be continued unless serum creatinine rises by more than 30% within four weeks. Contraception advice is recommended for women on ACEi or ARB therapy, with discontinuation advised for those considering pregnancy.

• Hyperkalaemia associated with ACEi, or ARB use can often be managed by measures to reduce serum potassium levels, avoiding immediate discontinuation or dose reduction. However, in the presence of symptomatic hypotension or uncontrolled hyperkalaemia despite medical intervention, dose reduction or discontinuation is warranted.

• The combination of ACEi with ARB or with a direct renin inhibitor is considered potentially harmful, using only one agent at a time to block the renin-angiotensin-aldosterone system.

• While effective for managing refractory hypertension, mineralocorticoid receptor antagonists may cause hyperkalaemia or a reversible decline in glomerular filtration, particularly in patients with a low estimated GFR.

• Monitoring glycaemic control through HbA1c is recommended, with twice-yearly measurements for long-term control. In cases of advanced CKD, a glucose management indicator derived from continuous glucose monitoring (CGM) data may be considered due to reduced reliability of HbA1c measurements.

• An individualised HbA1c target can be considered, ranging from <6.5% to <8.0%, is recommended for patients with diabetes and CKD not on dialysis. The achievement of lower targets may be facilitated by CGM, and alternative metrics such as time in range and time in hypoglycaemia.

Optimal strategies

As noted above, T2DM is the main driver of CKD. Effectively managing T2DM in patients living with CKD requires a multi-faceted approach that includes lifestyle changes and pharmacotherapy with metformin, sodium–glucose cotransporter-2 inhibitors (SGLT2i), glucagon-like peptide-1 receptor agonists (GLP-1RA), and additional medications (insulin, sulfonylureas, meglitinides) as needed for glycaemic control, according to the KDIGO guidelines. 5 KDIGO recommends initiating treatment with metformin for most patients with T2DM, CKD, and an estimated GFR ≥30ml/min/1.73m². Kidney transplant recipients living with T2DM and an estimated GFR >30ml/min/1.73 m² should also be treated with metformin, with careful monitoring and dose adjustments based on estimated GFR levels. Long-term use requires monitoring for vitamin B12 deficiency.5

For patients with T2DM, CKD, and an estimated GFR >30ml/min/1.73 m², KDIGO recommends SGLT2i as a first-line treatment, which provides benefits beyond glycaemic control (eg cardiovascular [CV] protection).5

The choice of SGLT2i should consider documented kidney or CV benefits and estimated GFR levels. KDIGO suggests cautious consideration for patients at risk of hypovolemia and emphasises continuing SGLT2i therapy even if estimated GFR falls <30 ml/min/1.73 m², unless not tolerated or kidney replacement therapy is initiated.5

For patients with T2DM and CKD who have not achieved individualised glycaemic targets with metformin and SGLT2i or cannot use those medications, KDIGO recommends long-acting GLP-1RA as an additional treatment. Prioritising agents with documented CV benefits is advised.5

To minimise gastrointestinal side effects, a low starting dose is recommended, and titration should be gradual. When GLP-1 RA is used concomitantly with other medications such as sulfonylureas or insulin, the doses of sulfonylurea and/or insulin may need to be reduced. GLP-1RA should not be used in combination with dipeptidyl peptidase-4 inhibitors.5

Lifestyle interventions

KDIGO recommends a personalised dietary approach. The diet should be rich in vegetables, fruits, whole grains, fibre, legumes, plant-based proteins, unsaturated fats, and nuts. Conversely, it should be limited in processed meats, refined carbohydrates, and sweetened beverages.5

Specifically for patients undergoing haemodialysis, and especially those on peritoneal dialysis, a protein intake between 1-1.2 grams/kg of body weight per day is suggested. Furthermore, KDIGO recommends keeping sodium intake <2 grams of sodium/day (equivalent to <90mmol of sodium per day, or <5 grams of sodium chloride per day [salt]) for patients living with diabetes and CKD.5

Physical activity is considered an essential component of managing diabetes and CKD. Patients living with diabetes and CKD should be encouraged to engage in moderateintensity physical activity for a cumulative duration of at least 150 minutes per week. However, the level of physical activity should be tailored to each patient’s CV and physical tolerance. Smokers should be encouraged to quit. 5 Patients living with obesity, diabetes, and CKD, should be encouraged to lose weight. This recommendation is particularly relevant for patients with an estimated GFR ≥30ml/min/1.73 m².5

These lifestyle interventions aim to optimise the overall health and well-being of patients living with diabetes and CKD. However, it is important for healthcare providers to individualise recommendations based on the patient’s specific health status, preferences, and any other relevant medical considerations. Regular monitoring and adjustments to the treatment plan may be necessary to achieve and maintain positive health outcomes.5

Conclusion

The alarming prevalence of chronic kidney disease (CKD) in Africa, affecting >2.5 million South Africans, emphasises the urgent need for comprehensive and equitable healthcare interventions. The disparities in health spending, workforce, and infrastructure revealed in the Global Kidney Health Atlas report highlights the complex landscape of CKD treatment.

While improvements in haemodialysis centres, transplantation facilities, and nephrologist prevalence have been noted, challenges persist, especially in low- and middle-income countries.

The KDIGO guidelines recommend personalised approaches, advocating for optimised patient care, the crucial role of lifestyle modifications, pharmacotherapy, and targeted interventions in improving global kidney care.

References are available on request. SF