Recent Trends in the Prevalence of Chronic Kidney Disease

Not the Same Old Song

Raymond K. Hsu; Neil R. Powe

Disclosures

Curr Opin Nephrol Hypertens. 2017;26(3):187-196. 

In This Article

Conclusion

Nation-level health examination surveys that include measurements of kidney function and albuminuria have allowed for tracking of the prevalence of CKD in recent decades in the United States and several other countries. Recent updates in the prevalence of CKD in the United States using NHANES suggest stable overall prevalence of CKD and stable prevalence of DKD since the 1999–2004 period.[10,18] The United States prevalence of eGFR less than 60 ml/min/1.73 m2 is estimated to be 6.9% in 2011–2012, whereas the prevalence of CKD stages 1–4 was 14.2% in the same period.[10] Several other developed countries such as Norway, England, and Korea have also seen a plateau (or downtrend in the case of Korea) in the prevalence of CKD since the early 2000s.[20–22,30,31] Although it is conceivable that this stability in CKD prevalence could be due to an increase in mortality rates among persons with CKD in the more recent years, to our knowledge there are no data to suggest that mortality rates among persons with CKD have worsened over time.

These findings underscore that strong efforts at treating risk factors for CKD such as lowering of BP, use of RAS-inhibitors, and improving glycemic control in those with diabetes have likely contributed to this reversal in the CKD epidemic.[19,30] Whether there are changes in the avoidance of use of nephrotoxins (e.g., radiographic contrast media, nonsteroidal anti-inflammatory agents, and other medication) in persons with CKD is unknown. The implication that better BP management may be modifying the disease prevalence of CKD is especially notable in light of the recently shifting, and somewhat uncertain targets, for hypertension treatment for CKD. The most recent 2014 Joint National Committee (JNC) 8 Hypertension Guidelines[46] recommended a relaxation in BP targets for those with CKD and diabetes (compared with the JNC 7 Guidelines[47]), whereas trial data from Systolic Blood Pressure Intervention Trial[48] suggested mortality and cardiovascular disease benefit with intensive control to SBP less than 120 mmHg in high cardiovascular risk patients (but with a potentially detrimental effect in loss of GFR in patients without baseline CKD with intensive BP control). Another common thread is that the stability of CKD prevalence occurred in the most recent decade despite an ongoing increase in the prevalence of diabetes and obesity across many populations, a sign that perhaps certain interventions that increased over time (i.e., glucose-lowering medications, improved glycemic control, and statin use) may overcome the initiation of CKD by these two risk factors.

Although these results are encouraging, a worrisome signal from the two recent US updates was that the burden of CKD continues to rise among racial-ethnic minorities (non-Hispanic blacks for overall CKD prevalence;[10] non-Hispanic blacks and Mexican-Americans for DKD prevalence[18]), with data from Afkarian et al.[18] suggesting that less-optimal care with regard to BP, diabetes, and lipid control may be playing a role. More aggressive efforts are necessary to better understand the complex interplay among biological, genetic, socioeconomic, and health system-level factors that contribute to this racial-ethnic disparity in trends.

Not all countries have well established surveillance systems to estimate and track CKD prevalence, but we have some glimpses at high-risk populations in some developing countries. In China, recent data from newly established population survey representative of its entire adult population showed overall CKD prevalence of 10% in 2009–2010,[33] a figure expected to rise due to the disproportionately low rates of stage 3 and above CKD compared with CKD stages 1–2 during the surveyed period. The development of accelerated CKD among young agricultural workers in parts of Central America illustrates the importance of identifying nontraditional risk factors such as occupational and environmental exposures in geographic regions where CKD is particularly endemic out of proportion to the rest of the population.

It would be helpful to develop better systematic and high-quality data collection worldwide on CKD and more granular data in local communities and healthcare systems. This would help to better monitor trends in the overall epidemic and among subgroups of the most vulnerable persons. Most importantly, such efforts would help identify the most promising strategies to disrupt rising trends in CKD prevalence or progression.

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