CKD Death and Disability Outpacing Other Chronic Diseases

Diana Swift

November 30, 2018

From 2002 to 2016, the burden of chronic kidney disease (CKD) in the United States grew faster than that of other noncommunicable diseases, according to the 2016 Global Burden of Disease Study. Loss of health and life increased substantially, particularly in younger adults aged 20 to 54 years.

"The findings suggest that an effort to target the reduction of CKD through greater attention to metabolic and dietary risks, especially among younger adults, is necessary," Benjamin Bowen, MPH, from the Clinical Epidemiology Center, Veterans Affairs St. Louis Health Care System in Missouri, and colleagues report in an article published online November 30 in JAMA Network Open.

"On a population and policy level, the rising burden in kidney disease must be reflected in public health policy priorities," author Ziyad Al-Aly, MD, also from Veterans Affairs St. Louis Health Care System, told Medscape Medical News.

Nearly 2 million healthy life-years were lost in 2016 to CKD, a 52.6% increase from 2002, and nearly 83,000 lives were lost to the disease, a 58.3% increase from 2002.

CKD-related disability-adjusted life years (DALYs) rose from 1,269,049 (95% uncertainty interval [UI], 1,154,521 - 1,387,008) to 1,935,954 (95% UI, 1,747,356 - 2,124,795). That translated to an increase of 35.9%, from 441 per 100,000 population (95% UI, 401 - 482) to 600 per 100,000 population (95% UI, 541 - 658). Age-standardized DALY rates rose by 18.6%, from 371 per 100,000 population (95% UI, 336 - 406) in 2002 to 440 (95% UI, 395 - 485).

The analysis indicated that the increase in CKD-related DALYs was related to increased risk exposure (40.3%), aging (32.3%), and population growth (27.4%).

The researchers analyzed the change in DALY rates with respect to four CKD-related causes: diabetes, hypertension, glomerulonephritis, and other causes. For these four categories, they found increases of 21.8%, 22.0%, 10.4%, and 10.3%, respectively.

The overall age-standardized DALY rates increased by 18.6%; increases in metabolic and dietary risk factors drove 93.8% and 5.3% of the change, respectively.

As for mortality, CKD-driven deaths increased overall by 58.3%, from 52,127 (95% UI, 51,082 - 53,076) in 2002 to 82,539 (95% UI, 80,298 - 84,652). That represented a rise of 41.1%, from 18 per 100,000 population to 26 per 100,000. The age-standardized death rate increased by 17.9%.

In people aged 20 to 54 years, the probability of CKD-related death increased from 0.099% to 0.125%, an increase of 26.8%. The increase was largely driven by diabetes (69.1%).

Diabetes-related CKD was the main impetus for the 26.8% increased probability of CKD death in patients aged 20 to 54 years. Among those aged 55 to 89 years, the probability of CKD-related death rose by 25.6%; again the increase was driven by diabetes-related CKD. The probability of death from non-CKD causes decreased.

Increases varied widely by state, but all jurisdictions saw the CKD toll rise. Oklahoma saw the greatest change, with a rise in DALY rate of 32.9%. The lowest increase, of 6.3%, occurred in Nevada.

Overall, Mississippi and Louisiana (in which the burden was highest) exhibited more than twice the burden seen in other jurisdictions, such as Vermont and Washington (lowest burdens). In Vermont, the age-standardized DALY was 321 (95% UI, 281 - 363) per 100,000 population, vs Mississippi's 697 (95% UI, 620 - 779) and Louisiana's 681.

Louisiana and Mississippi also had the highest age-standardized CKD death rates: 28 and 27 per 100,000 population, respectively.

With regard to CKD risk factors in the population, the researchers identified metabolic variables, such as high fasting plasma glucose levels, high body mass index (BMI), and high systolic blood pressure. Dietary risks included high sodium intake and high consumption of sugar-sweetened beverages.

"At the individual patient level, we think patients should pay attention to diet by reducing consumption of calorie-dense food, sugary drinks, and sodium," Al-Aly said. "Efforts should be made to reduce BMI to healthy levels in those who are obese and treat blood pressure in those with elevated blood pressure."

The CKD toll in the United States outpaced global epidemiologic trends and was linked to changing demographics and socioeconomic development. During the study period, the US population grew from 287 million to 323 million, and life expectancy increased from 76.8 to 78.8 years. The sociodemographic index, a measure of income, education, and fertility rates, also increased, but sociodemographic development and exposure to CKD risk factors increased in tandem. So unlike other noncommunicable diseases, for which age-standardized DALYs dropped, the CKD rate increased with sociodemographic index in all states but the District of Columbia.

"With more sociodemographic progress, we usually expect to see decline in burden of disease. This was certainly true for cancer, cardiovascular disease, and the category of all noncommunicable diseases," Al-Aly said. "This likely reflects the fact that as we experienced sociodemographic progress, we did better at developing treatments for and early identification and early treatment of diseases like heart disease and cancer, but this is not true for CKD. There are not new meaningful therapies for CKD that would have changed the burden."

The increased CKD burden should be addressed through the allocation of resources at the state and federal levels, the authors conclude.

The study was supported in part by the Institute for Public Health at Washington University, St Louis, and the US Department of Veterans Affairs. The authors have disclosed no relevant financial relationships.

JAMA Netw Open. Published online November 30, 2018. Full text

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