Mind the gap in kidney care: translating what we know into what we do

Abstract

Historically, it takes an average of 17 years for new treatments to move from clinical evidence to daily practice. Given the highly effective treatments now available to prevent or delay kidney disease onset and progression, this is far too long. Now is the time to narrow the gap between what we know and what we do. Clear guidelines exist for the prevention and management of common risk factors for kidney disease, such as hypertension and diabetes, but only a fraction of people with these conditions are diagnosed worldwide, and even fewer are treated to target. Similarly, the vast majority of people living with kidney disease are unaware of their condition, because it is often silent in the early stages. Even among patients who have been diagnosed, many do not receive appropriate treatment for kidney disease. Considering the serious consequences of kidney disease progression, kidney failure, or death, it is imperative that treatments are initiated early and appropriately. Opportunities to diagnose and treat kidney disease early must be maximized beginning at the primary care level. Many systematic barriers exist, ranging from the patient to the clinician to the health systems to societal factors. To preserve and improve kidney health for everyone everywhere, each of these barriers must be acknowledged so that sustainable solutions are developed and implemented without further delay.

Figure 1. All ages, top 10 global risk factors for death, 2019. Kidney dysfunction (defined as estimated glomerular filtration rate <60 mL/min per 1.73 m or albumin-to-creatinine ratio ≥30 mg/g) was the seventh leading global level 3 risk factor for death in 2019. The 3 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 Figure S1. Data obtained from the Global Burden of Disease Study. Abbreviations – BMI: body mass index; LDL: low-density lipoprotein.

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. Most data come from resource-high settings; these proportions are likely lower in resource-low settings. Data are shown for proportions of patients reaching blood pressure of <130/80 mm Hg. Data compiled from previous studies ^- . Abbreviation – HbA1c: hemoglobin A1c.

Figure 3. Recommended optimal lifestyle and therapeutic management for chronic kidney disease (CKD) in diabetes. Illustration of a comprehensive and holistic approach to optimal 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 integral to kidney care.

Figure 4. Depiction of the spectrum of factors impacting implementation of timely and quality kidney care.

Figura 1. Todas as idades, 10 principais fatores de risco globais para óbito, 2019. A disfunção renal (definida como taxa de filtração glomerular estimada <60 mL/min por 1,73 m² ou relação albumina/creatinina ≥30 mg/g) foi o sétimo principal fator de risco global de nível 3 para óbito em 2019. Os três principais fatores de risco globais para doenças renais, incluindo hipertensão, diabetes e sobrepeso/obesidade, também são os principais fatores de risco globais para óbito; portanto, são necessárias estratégias holísticas para abordar todos os fatores de risco simultaneamente. A classificação é representada por milhões se os óbitos forem atribuídos aos fatores de risco. As barras de erro representam o intervalo de confiança. A classificação global de disfunção renal estratificada por categoria de renda do Banco Mundial e por sexo é mostrada na Figura Suplementar S1. Dados obtidos do estudo Global Burden of Disease ². Abreviações – IMC: índice de massa corporal; LDL: lipoproteína de baixa densidade.

Figura 2. Proporção de pessoas com doença renal crônica (DRC) que têm conhecimento de seu diagnóstico e estão recebendo o cuidado adequado recomendado pelas diretrizes. A proporção de pessoas com DRC que estão cientes de seu diagnóstico varia em todo o mundo, com taxas que vão de 7% a 20%. À medida que o estágio da DRC piora, o conhecimento sobre a doença aumenta. Entre aqueles com diagnóstico de DRC, a proporção média de pacientes que recebem medicação adequada para retardar a progressão da DRC (inibidores do sistema renina-angiotensina-aldosterona [SRAA] e inibidores do cotransportador de sódio-glicose 2 [SGLT2]) está abaixo do ideal, assim como aqueles que atingem a pressão arterial alvo, controle do diabetes e orientação nutricional. As metas de tratamento descritas na figura seguem as diretrizes do KDIGO (Kidney Disease: Improving Global Outcomes) de 2012¹⁵. A maioria dos dados é proveniente de cenários com muitos recursos; essas proporções provavelmente são menores em ambientes com recursos limitados. Os dados são mostrados para proporções de pacientes que atingem pressão arterial <130/80 mm Hg. Dados compilados de estudos anteriores ^– . Abreviação – HbA1c: hemoglobina A1c.

Figura 3. Manejo terapêutico e estilo de vida ideais recomendados para a doença renal crônica (DRC) no diabetes. Ilustração de uma abordagem abrangente e holística para a saúde renal ideal em pessoas com DRC. Além dos ajustes fundamentais no estilo de vida, a atenção ao controle do diabetes, da pressão arterial (PA) e dos fatores de risco cardiovascular é essencial para o cuidado com os rins.

Figura 4. Representação do espectro de fatores que afetam a implementação de cuidados renais oportunos e de qualidade.