Editorial
Although historically regarded as a severe lifethreatening disorder affecting only a few people, chronic kidney disease (CKD) is now recognised to occur in many people, with graded severity. Far from rare, an estimated 10% of the world’s population are thought to have CKD. Globally, CKD was responsible for about 730 000 deaths in 2010, a number almost double the 400 000 deaths attributable to the disease in 1990. The global burden of acute kidney failure, the most serious outcome of CKD, is calculated to be 13·3 million cases per year, 11·3 million of which are in low-income countries. Diabetes and hypertension are major risk factors for CKD, and as the prevalence of these disorders increases, so does the frequency of CKD. Most of the burden of noncommunicable diseases—including obesity, diabetes, hypertension, cardiovascular disease, and CKD—is now borne by low-income and middle-income countries (LMICs). Worryingly, the prevalence of diabetes and obesity in high-income countries is beginning to stabilise while it continues to increase in LMICs. The organisation Kidney Disease: Improving Global Outcomes, which develops global clinical practice guidelines for CKD, advocates prevention, early detection and management, and screening of patients at high risk. Kidney damage can be reversible, and early intervention can delay progression in advanced disease. As outlined in two Reviews in this month’s issue of The Lancet Diabetes & Endocrinology, our understanding of the molecular basis of kidney disease and its pathophysiology is steadily increasing. However, good evidence to guide detection, assessment, and management of CKD is still scarce. Managing possible causative factors can help to prevent development of CKD and delay its progression. In people with diabetes, some treatments can both improve glycaemic control and have a positive effect on renal function, as shown by Anthony Barnett and colleagues’ study with the SGLT2 inhibitor empagliflozin in diabetic patients with stage 2 CKD. Unfortunately, clinical trials in patients with CKD are difficult both to do and interpret, in view of the high frequency of comorbid disease in this population, the need for multidisciplinary care, and the long follow-up needed. For patients who have progressed to end-stage kidney failure, dialysis or transplantation are currently the only long-term treatment options. These interventions are www.thelancet.com/diabetes-endocrinology Vol 2 May 2014
costly, highly invasive, and involve lifelong treatment and follow-up. Some people might not be deemed eligible for transplant—eg, because of poor health. In some countries, others are denied renal replacement therapy altogether because the health system cannot support lifelong treatment. Worldwide, access to renal replacement therapy, such as dialysis, is restricted to fewer than 5% of patients who need it. However, whereas haemodialysis is expensive and requires specialist staff and equipment, peritoneal dialysis has shown promise in LMICs. Other innovative approaches, such as transplantation of kidneys from individuals infected with HIV to patients with the same status, as done in South Africa, have been successful. Such outside-the-box thinking that increases the availability of treatment should be encouraged. According to new research by the Institute for Health Metrics and Evaluation at the University of Washington, global health funding hit an all-time high of US$31·3 billion in 2013. However, non-communicable diseases are not a main focus of development assistance for health, leading to a huge gap between the money available to fund programmes to prevent and treat non-communicable diseases and their burden. At the 12th International Congress on Obesity (Kuala Lumpur, March 17–20, 2014), Amanda Lee (Professor of Public Health and Nutrition at Queensland University of Technology, Brisbane, QLD, Australia) had a cautionary tale to tell. In 1980, she and her team applied for a grant of AU$30 000 to fund a simple community intervention in a rural indigenous Australian population—changing the local takeaway to a healthy option—and this proposal was turned down. Last year, because of a lack of successful interventions to prevent or reverse the rise in non-communicable diseases, the prevalence of obesity, diabetes, and CKD in this community had increased to such an extent that the local hospital needed to spend AU$1·4 million on dialysis facilities. As with other complications of obesity, CKD is expensive and challenging to treat when in advanced stages, despite being largely preventable and reversible if detected early. Funding is urgently needed for research into interventions that will prevent CKD, for developing new treatments, and for improving access to existing and emerging treatments for those who need them. ■ The Lancet Diabetes & Endocrinology
Life in View/Science Photo Library
Kidney failure: are we failing?
For the Lancet Series on Global kidney disease see http://www. thelancet.com/series/globalkidney-disease For more on chronic kidney disease see Seminar Lancet 2012; 379: 165–80 For more on the global burden of kidney disease see http:// www.thelancet.com/themed/ global-burden-of-disease For more on acute kidney failure see http://www.thelancet.com/ journals/lancet/article/ PIIS0140-6736(13)62193-5/ fulltext?_eventId=login#bib7 For Kidney Disease: Improving Global Outcomes see http:// kdigo.org/ For the study by Barnett and colleagues see http://www. thelancet.com/journals/landia/ article/ PIIS2213-8587(13)70208-0/ fulltext?_eventId=login For the Saving Young Lives project using sustainable programs for treating kidney disease see http://www.theisn. org/isn-information/savingyoung-lives-in-africa-and-asia/ itemid-1050 For more on kidney transplantation between patients infected with HIV see http://www.thelancet.com/ journals/lancet/article/ PIIS0140-6736(12)60749-1/ fulltext For more on the research by the Institute for Health Metrics and Evaluation see http://www. healthmetricsandevaluation.org/ publications/policy-report/ financing-global-health-2013transition-age-austerity
349
Although historically regarded as a severe lifethreatening disorder affecting only a few people, chronic kidney disease (CKD) is now recognised to occur in many people, with graded severity. Far from rare, an estimated 10% of the world’s population are thought to have CKD. Globally, CKD was responsible for about 730 000 deaths in 2010, a number almost double the 400 000 deaths attributable to the disease in 1990. The global burden of acute kidney failure, the most serious outcome of CKD, is calculated to be 13·3 million cases per year, 11·3 million of which are in low-income countries. Diabetes and hypertension are major risk factors for CKD, and as the prevalence of these disorders increases, so does the frequency of CKD. Most of the burden of noncommunicable diseases—including obesity, diabetes, hypertension, cardiovascular disease, and CKD—is now borne by low-income and middle-income countries (LMICs). Worryingly, the prevalence of diabetes and obesity in high-income countries is beginning to stabilise while it continues to increase in LMICs. The organisation Kidney Disease: Improving Global Outcomes, which develops global clinical practice guidelines for CKD, advocates prevention, early detection and management, and screening of patients at high risk. Kidney damage can be reversible, and early intervention can delay progression in advanced disease. As outlined in two Reviews in this month’s issue of The Lancet Diabetes & Endocrinology, our understanding of the molecular basis of kidney disease and its pathophysiology is steadily increasing. However, good evidence to guide detection, assessment, and management of CKD is still scarce. Managing possible causative factors can help to prevent development of CKD and delay its progression. In people with diabetes, some treatments can both improve glycaemic control and have a positive effect on renal function, as shown by Anthony Barnett and colleagues’ study with the SGLT2 inhibitor empagliflozin in diabetic patients with stage 2 CKD. Unfortunately, clinical trials in patients with CKD are difficult both to do and interpret, in view of the high frequency of comorbid disease in this population, the need for multidisciplinary care, and the long follow-up needed. For patients who have progressed to end-stage kidney failure, dialysis or transplantation are currently the only long-term treatment options. These interventions are www.thelancet.com/diabetes-endocrinology Vol 2 May 2014
costly, highly invasive, and involve lifelong treatment and follow-up. Some people might not be deemed eligible for transplant—eg, because of poor health. In some countries, others are denied renal replacement therapy altogether because the health system cannot support lifelong treatment. Worldwide, access to renal replacement therapy, such as dialysis, is restricted to fewer than 5% of patients who need it. However, whereas haemodialysis is expensive and requires specialist staff and equipment, peritoneal dialysis has shown promise in LMICs. Other innovative approaches, such as transplantation of kidneys from individuals infected with HIV to patients with the same status, as done in South Africa, have been successful. Such outside-the-box thinking that increases the availability of treatment should be encouraged. According to new research by the Institute for Health Metrics and Evaluation at the University of Washington, global health funding hit an all-time high of US$31·3 billion in 2013. However, non-communicable diseases are not a main focus of development assistance for health, leading to a huge gap between the money available to fund programmes to prevent and treat non-communicable diseases and their burden. At the 12th International Congress on Obesity (Kuala Lumpur, March 17–20, 2014), Amanda Lee (Professor of Public Health and Nutrition at Queensland University of Technology, Brisbane, QLD, Australia) had a cautionary tale to tell. In 1980, she and her team applied for a grant of AU$30 000 to fund a simple community intervention in a rural indigenous Australian population—changing the local takeaway to a healthy option—and this proposal was turned down. Last year, because of a lack of successful interventions to prevent or reverse the rise in non-communicable diseases, the prevalence of obesity, diabetes, and CKD in this community had increased to such an extent that the local hospital needed to spend AU$1·4 million on dialysis facilities. As with other complications of obesity, CKD is expensive and challenging to treat when in advanced stages, despite being largely preventable and reversible if detected early. Funding is urgently needed for research into interventions that will prevent CKD, for developing new treatments, and for improving access to existing and emerging treatments for those who need them. ■ The Lancet Diabetes & Endocrinology
Life in View/Science Photo Library
Kidney failure: are we failing?
For the Lancet Series on Global kidney disease see http://www. thelancet.com/series/globalkidney-disease For more on chronic kidney disease see Seminar Lancet 2012; 379: 165–80 For more on the global burden of kidney disease see http:// www.thelancet.com/themed/ global-burden-of-disease For more on acute kidney failure see http://www.thelancet.com/ journals/lancet/article/ PIIS0140-6736(13)62193-5/ fulltext?_eventId=login#bib7 For Kidney Disease: Improving Global Outcomes see http:// kdigo.org/ For the study by Barnett and colleagues see http://www. thelancet.com/journals/landia/ article/ PIIS2213-8587(13)70208-0/ fulltext?_eventId=login For the Saving Young Lives project using sustainable programs for treating kidney disease see http://www.theisn. org/isn-information/savingyoung-lives-in-africa-and-asia/ itemid-1050 For more on kidney transplantation between patients infected with HIV see http://www.thelancet.com/ journals/lancet/article/ PIIS0140-6736(12)60749-1/ fulltext For more on the research by the Institute for Health Metrics and Evaluation see http://www. healthmetricsandevaluation.org/ publications/policy-report/ financing-global-health-2013transition-age-austerity
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