editorial [Link]-international.

org

A single number for advocacy and

communication—worldwide more than
Kitty J. Jager1,8, 850 million individuals have kidney diseases
Csaba Kovesdy2,8, Kidney International (2019) 96, 1048–1050; [Link]
Robyn Langham3,8, KEYWORDS: chronic kidney disease; kidney development
Mark Rosenberg4,
Copyright ª 2019 The Authors. Published by Elsevier Inc. on behalf of the International Society of Nephrology.
Vivekanand Jha5,6 and
Carmine Zoccali7
1
ERA-EDTA Registry,
n a world scale the total number of However, the degree of complexity of these

O
Amsterdam UMC, University of
Amsterdam, Department of individuals with chronic kidney disease statistics is such that they are not easily used for
Medical Informatics, (CKD), acute kidney injury (AKI), and communication with the public and with deci-
Amsterdam Public Health
Research Institute, Amsterdam,
those on renal replacement therapy (RRT) ex- sion makers. The differentiation of CKD into
The Netherlands; 2Division of ceeds 850 million, a truly concerning figure that stages and the separate consideration of the
Nephrology, Department of is twice the estimated number of people with epidemiology of patients on RRTs (dialysis and
Medicine, University of diabetes worldwide and >20 times higher than transplantation) are fundamental in profes-
Tennessee Health Science the number of individuals affected by AIDS/ sional and scientific terms but are too complex
Center, Memphis, Tennessee,
USA; 3School of Rural Health,
HIV worldwide. Thus kidney diseases are one to serve as a basis for broad-based communi-
Monash University, Melbourne, of the most common diseases worldwide. cation. AKI, related to basic public health
Victoria, Australia; 4Education CKD is now an unquestionable global public challenges, continues to be an important cause
and Academic Affairs, priority.1,2 Even though the prevalence of CKD of entirely preventable deaths throughout the
University of Minnesota Medical developing world. Survivors are at increased
and its impact on health has been mainly studied
School, Minneapolis,
Minnesota, USA; 5George in economically developed countries, the burden risk of developing CKD. Fragmentation of dis-
Institute for Global Health, New of this disease is even greater in developing cussion by framing these conditions separately
Delhi, India; 6University of countries.3,4 In 2016, this disease was 13th on the leads to the removal of focus from the impor-
Oxford, Oxford, UK; and 7CNR- list of causes of death on a world scale,5 and in tance of the health burden imposed on the so-
IFC Clinical Epidemiology of ciety by disruption of normal kidney function.
2040, it is expected to be the 5th leading cause of
Renal Diseases and
Hypertension, Reggio Cal, Italy years of life lost.6 In 2010, 2.6 million individuals A simplification effort is needed if we are to
were receiving some form of kidney replacement increase awareness of the extent of the magni-
This article is a joint project
by the American Society of therapy worldwide, but an almost equal number tude of kidney diseases on a global scale. Pro-
Nephrology (ASN), European might have died during the same year because of ducing a single, absolute number of individuals
Renal Association–European a lack of access to dialysis and transplantation.7 affected by kidney diseases will effectively
Dialysis and Transplant Asso- This scenario contrasts with that of other ma- convey to the interested parties the large and
ciation (ERA-EDTA), and the growing relevance of the problem.
jor chronic diseases, such as cardiovascular dis-
International Society of
Nephrology (ISN). eases and respiratory diseases, whose effects on
mortality are declining.8 Kidney diseases: statistics for communication
This article has been co-
published with permission in In spite of this recent recognition of the and advocacy
Nephrology, Dialysis, Trans- adverse impact of CKD on health outcomes, Producing simple, immediately understandable
plantation and Kidney Inter- awareness of the magnitude and the risks of statistical figures is fundamental for helping to
national. All rights reserved this condition remain low at the population draw attention to unaddressed public health is-
in respect of Nephrology,
level. As a result, kidney disease has been largely sues by governments and health authorities and
Dialysis, Transplantation ª
The Authors, and in respect overlooked by health authorities and govern- to increase awareness at the community level.12
of Kidney International, ª The ments in most countries.9 Even in the USA, a The international diabetes community has had
Authors. Published by Elsev- 2016 survey10 showed that CKD awareness in significant success in leveraging increased
ier Inc. on behalf of Interna- the community is substantially lower as awareness and support by identifying and using
tional Society of Nephrology.
All rights reserved. The arti-
compared with that of other chronic diseases a single figure that conveys the global burden of
cles are identical except for such as hypertension and diabetes.11 diabetes, a figure that is independent of the type
minor stylistic and spelling Kidney diseases cover a wide spectrum of and severity of diabetes.13 Other examples
differences in keeping with diseases with diverse etiologies, clinical courses, include depression,14,15 Alzheimer’s,16 and
each journal’s style. Either and functional severity, from AKI to the various breast cancer.17 Thus it is of great importance to
citation can be used when
CKD stages from stage 1 to stage 5, and include have a similar metric to express the burden of
citing this article.
end-stage kidney disease, which demands kidney diseases across the globe.
Correspondence: Carmine
Zoccali, CNR-IFC Clinical
chronic dialysis and renal transplantation. With this background in mind, the ASN,
Epidemiology of Renal Diseases Several countries have now produced rich, ar- ERA-EDTA, and ISN in 2017 convened a group
and Hypertension, Reggio Cal, ticulated, and very detailed CKD statistics. charged with producing a simple global

1048 Kidney International (2019) 96, 1048–1050

 editorial

Italy. E-mail: [Link]@ estimate of the number of individuals affected Table 1 | The global dimension of kidney
[Link] by kidney disease, irrespective of etiology, diseases in 2017
8
These authors contributed chronicity, severity, or treatment modality. A CKD stages 1–5 843.6 million
equally to this work. group of experts representing these societies Individuals with AKI 13.3 million
Received 24 July 2019; met twice in face-to-face meetings and held 3 Individuals on RRT 3.9 million
editorial decision 26 July teleconferences to discuss a pragmatic Total 860.8 million
2019; published online 30
September 2019
approach to determining this single number to AKI, acute kidney injury; CKD, chronic kidney disease; RRT, renal
replacement therapy.
truly convey the essence of the epidemic facing
the global community.
number of patients on RRT given by Liyanage
The single number: assumptions, key studies, et al.7 for 2010 is 2.618 million. A 4.5%
and calculations growth per year in a stable world population
The setting date for calculation was the year would result in 3.562 million in 2017. Addi-
2017. In this year, the world population (rounded tional correction for the growth of the world
off to the first decimal) was 7.6 billion.18 population (from 7 to 7.6 billion, i.e., 8.57%)
We assumed an equal distribution of the then gives a number of 3.868 million,
world population between males and females rounded off to 3.9 million.
and a homogeneous and stable prevalence of All in all, the sum of individuals with CKD,
CKD among different parts of the world. The AKI, and those on RRT (Table 1) gives a figure
estimate was based on figures reported in the exceeding 850 million, a truly concerning figure
systematic review by Mills et al.19 This review that is twice the estimated number of people
collated 33 studies published between 2006 and with diabetes worldwide (422 million in
2013 reporting the gender- and age-specific 2014)22 and >20 times higher than the number
prevalence of CKD in representative population of individuals affected by AIDS/HIV worldwide
samples in 32 countries including high income (36.9 million in 2017).23 Thus the data have
(18 countries) and low and middle income (14 identified that kidney diseases are one of the
countries). The global prevalence of CKD in this most common diseases worldwide.
review was 11.1% (10.4% among men and
11.8% among women), which is tantamount to CONCLUSION
an absolute global number of individuals with Even though pragmatic estimates of the global
CKD of 843.6 million (prevalence  world burden of kidney diseases based on a single
population, 11.1%  7.6 billion). number have already been made,2 this number
To calculate the total number of individuals rests on data of various qualities and on ap-
with AKI worldwide, the estimates made by proximations and demands some assumptions.
Lewington et al.20 were adopted. Since data on The 3 societies plan to update the number on a
AKI in low- and middle-income countries are regular basis, thus allowing monitoring of the
extremely limited,21 Lewington et al.20 assumed global burden of kidney diseases over time.
that the AKI incidence in these countries is the Awareness of the global burden of diseases is a
same as that in high-income countries. Overall, prerequisite for acceptance by the community,
the resulting figures were 2 million/yr in high- policymakers, and public health groups that
income countries and 11.3 million/yr in low- leads to commitment to institution of public
and middle-income countries, which translates health approaches that will improve health
into a global estimate of 13.3 million cases of outcomes.
AKI/yr.
Finally, the total number of individuals DISCLOSURE
treated with RRT worldwide (3.9 million) was All the authors declared no competing interests.
estimated by data reported in the systematic
review by Liyanage et al.7 For this calculation, ACKNOWLEDGMENTS
the growth rate of the RRT population was The authors acknowledge Monica Fontana (ERA-
assumed to be equal to that observed in the EDTA Executive Manager), who coordinated the
ERA-EDTA and US (United States Renal Data project, and Rachel Meyer (ISN) and Tod Ibrahim
System) dialysis registries in the years 2010– (ASN), who actively participated in the realization of
the same project.
2014, which was 4.5%. Furthermore, it was
assumed that the RRT population would AUTHOR CONTRIBUTIONS
grow at the same rate as the world population KJJ, CK, and RL made the literature search and set the
(i.e., 8.75% between 2010 and 2017). The methodology for calculating the “single number” and

Kidney International (2019) 96, 1048–1050 1049

editorial

finally produced it. CZ (ERA-EDTA President) wrote 9. Stanifer JW, Von Isenburg M, Chertow GM, et al.
the first draft of the article that was then revised by Chronic kidney disease care models in low- and
KJJ, CK, and RL and by the leadership of the ISN (VJ middle-income countries: a systematic review. BMJ
Glob Health. 2018;3:e000728.
and, in particular, Adeera Levin—Past President, who
10. Narva AS, Briggs M, Jordan R, et al. Toward a more
also gave an important contribution in the initial
collaborative federal response to chronic kidney
phases of the joint project) and the ASN (MR and disease. Adv Chronic Kidney Dis. 2010;17:282–288.
Mark Okusa, Past President of ASN). All authors 11. Tuot DS, Zhu Y, Velasquez A, et al. Variation in
approved the final version of the manuscript. patients’ awareness of CKD according to how they are
asked. Clin J Am Soc Nephrol. 2016;11:1566–1573.
12. Djordjevic N. 30 Staggering Healthcare Statistics to
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