COMMENTARY

Burden of CKD in the United States: What Have We Learned?

Tejas P. Desai, MD

Disclosures

April 05, 2019

There has been a tremendous resurgence of randomized controlled trials in nephrology. Trials such as LIRICO[1] and PIVOTAL[2] are "reintroducing" the younger generation of nephrologists to exciting areas of research.

Although these trials can have a direct effect on our day-to-day practices, we must not forget that nonrandomized trials also have a place in the field—specifically, large epidemiologic studies, which admittedly have less of an influence on the care we deliver at the patient level. Such studies, although not as sexy as randomized trials, exert a great influence on the way the nephrology community, national governments, and other stakeholders allocate healthcare resources. On a macro scale, these "epi" studies can identify underresourced areas that require more financial and human capital.

A perfect case in point is the recently published 15-year look of the burden of chronic kidney disease (CKD) in the United States.[3] Using data from the Global Health Data Exchange, Bowe and colleagues aimed to quantify and trend the burden of CKD in America with the hopes of identifying underresourced areas that require further stakeholder attention.

The researchers looked at four measures of disease burden in performing this analysis:

  • Years of life lost

  • Years living with the disability

  • Disability-adjusted life-years(DALY)

  • Death

For the purposes of the study, CKD was defined as having an estimated glomerular filtration rate of < 60 mL/min/1.73 m2. The researchers quantified and calculated these disease burden metrics across the United States in 2002 and 2016 and compared the results against each other, adjusting for state-specific burden, sociodemographic index, and population size.

Perhaps not surprisingly, but somewhat alarmingly, the data show a worsening of CKD burden in nearly all 50 states. In the past 15 years, every state had a high CKD burden, as measured by DALY metrics, with three states in the Deep South (Mississippi, Louisiana, and Alabama) having the highest rates in 2016. From 2002 to 2016, Oklahoma, West Virginia, and Texas had the largest percent change in DALY and the state with the lowest percent change was Nevada.

 

The analysis revealed similar findings when using death as the measure of CKD burden. In 2016, the states with the largest burden of CKD (by death) were Mississippi, West Virginia, and Alabama. Only one state, Nevada, showed an improvement in CKD burden as measured by death; the remaining 49 all had a greater CKD burden. Finally, those with higher sociodemographic status (a sociodemographic index close to 1) had a greater CKD burden, making CKD one of a few noncommunicable diseases that show this relationship.

 

Questions This Study Raises

Analyses such as these are absolutely necessary to identify "problem areas" that require intense interventions on a macro scale. Should states in the Deep South receive more governmental funding to tackle the runaway CKD burden that currently exists? How should that funding be allocated?

Should federal agencies offer debt relief to graduating trainees who choose to work in areas of great CKD burden? In contrast, for those trainees who do not have tremendous debt (eg, international medical graduates), should an expedited green card or visa program be created for those who choose to work a minimum number of years in heavily burdened states?

Finally, should changes be made to the Affordable Care Act that specifically address the CKD needs of citizens of highly burdened states?

There are many conventional and "out of the box" ideas that should be considered after reading this analysis. Which resources should be re-allocated on the basis of these data, and how should that happen? Tell us what you think in the comment section, and be sure to check out the infographic that accompanies this perspective.

Follow Tejas P. Desai, MD, on Twitter: @nephondemand

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