A conservative estimate suggests that CKD likely afflicts some 80 million people in South Asia.
Chronic kidney disease (CKD) is arguably emerging as a major threat to the developing world. The word ‘arguably” is used deliberately because while we know that CKD in the United States affects approximately 5%-10% of the population (Am J Kidney Dis. 2003;41:1-12) and is a major risk factor for CVD and all-cause mortality, similar data from the developing world is unavailable.
If one were to conservatively extrapolate the CKD prevalence rate to countries in South Asia using a prevalence rate just one half of the U.S. rate (see table), the statement that “CKD is emerging as a major threat” would not be that controversial. Some 80 million people in South Asia alone are likely to have CKD based on this simple extrapolation. Indeed, recent data suggest that Asians are at higher risk for CKD than Caucasians (Kidney Int. 2005;68:2310-2316) and that poverty is an important risk factor for CKD, so, if anything, these extrapolations are likely to be an underestimate.
In contrast to the situation in wealthy nations, where the development of kidney failure allows for dialytic support or transplantation, in most parts of the developing world kidney failure represents a death sentence. Consequently, even if only 10% of the hypothetical 80 million with CKD in South Asia went on to develop kidney failure, the death rate would be staggering.
The economic effects are also likely to be profound, worse in very poor countries. In this article, what follows is a discussion of CKD examined through the lens of health policy in the poor countries of the world and then a discussion focusing on the opportunities and challenges of screening for kidney disease in these countries.
As with many diseases, CKD has deleterious effects on both the health of individuals and on society as a whole. CKD impacts on both quality of life (Kidney Int. 2005;68:2801-2808; Am J Kidney Dis. 2005; 45:658-666) and longevity (N Engl J Med. 2004;351:1296-1305). Several studies demonstrate a markedly higher rate of CVD in CKD patients (JAMA. 2005;293:1737-1745; Am J Kidney Dis. 2004;44:198-206; J Am Soc Nephrol. 2005;16:3728-3735). Mortality is higher in CKD patients and increases in a graded fashion with a progressive decline in kidney function.
Among individuals with CKD, there is a five- to 10-fold increase in the rate of hospitalization compared with healthy people. Analyses from the United States indicate that the cost of a CKD patient to the health-care system is three- to fivefold higher than that of a healthy individual (Kidney Int. 2004;66:313-321). CKD also increases the morbidity associated with other chronic conditions such as congestive heart failure (J Card Fail. 2004; 10:467-472; J Am Soc Nephrol. 2002; 13:1928-1936). The end result of CKD progression is irreversible kidney failure requiring renal replacement therapy. In the United States, the annual cost of taking care of a patient on hemodialysis averages around $60,000 (J Am Soc Nephrol. 1998;9:884-890).
In the developing world, even adjusting for a lower cost structure for dialysis and health care, the cost of kidney failure still remains outside the reach of most patients. Because CKD is a major risk factor for CVD, any growth in CKD prevalence almost certainly results in an increase in the incidence of CVD and its associated human and economic cost. Although CKD may not have the immediacy of famine, natural disasters, and epidemics such as the AIDS crisis, it has the potential in poor countries to be associated with significant mortality and substantial cost.