Rising Burden of Hypertensive Chronic Kidney Disease Worldwide (2000–

2023): Age-Standardized Rates and Gender Disparities from Global Burden

of Disease 2023
Abstract

Background
Chronic kidney disease (CKD) affects about 9–10% of the global population and its burden is
rising, causing 1.53 million deaths in 2021. Hypertension, present in up to 90% of CKD
patients, is a key modifiable risk factor; blood pressure control is vital to prevent progression.

Methods
We analyzed publicly available data from the Global Burden of Disease (GBD) 2023 study to
assess the impact of hypertension on chronic kidney disease (CKD-HTN) from 2000 to 2023.
We examined global incidence, prevalence, mortality, and disability-adjusted life years
(DALYs), stratified by gender, and compared estimates from 2000 and 2023 to evaluate
temporal change.

Results
From 2000 to 2023, global age-standardized death rates from CKD-HTN increased by 76.8%,
DALYs by 58.1%, incidence by 41.5%, and prevalence by 37.7%. Men consistently had higher
mortality and DALY rates while incidence and prevalence rates were higher in females. In
2000, male prevalence was 465.02 vs. female 537.49 (∆ = 72.47), rising to 648.43 vs. 731.75
in 2023 (∆ = 83.32).

Conclusion
The burden of hypertensive CKD has increased significantly over the past two decades,
disproportionately affecting men in terms of mortality and overall disease burden, while also
affecting women more in terms of disease prevalence and incidence. These findings highlight
the urgent need for improved blood pressure control, targeted screening programs for both men
and women, and public health interventions to address the growing problem of hypertensive
kidney disease worldwide.

1
Introduction

Chronic kidney disease (CKD) is a major global public health problem[1]. In 2021, about
674 million people worldwide were estimated to have CKD (age-standardized prevalence
≈8000 per 100,000), implying roughly 9–10% of the population[2]. CKD accounted for
~1.53 million deaths and 44.5 million DALYs in 2021[2]. The CKD burden is rising
sharply: global prevalence increased by roughly 33% from 1990 to 2017, driven mainly
by population growth and aging[3]. CKD is more common in low- and middle-income
regions, and there are important sex differences: women generally have higher CKD
prevalence than men, while men have higher mortality and are more likely to progress
to kidney failure[2,4].

Hypertension is one of the most important modifiable risk factors for CKD [5,6]. In
many CKD patients, hypertension is both a cause and a consequence of kidney
damage: up to 90% of people with CKD have hypertension, which can accelerate
progression to advanced kidney disease[7]. In high-income settings, an estimated one
in five people with hypertension has CKD[2]. Conversely, high blood pressure greatly
increases the risk of developing CKD/ESRD: meta-analyses suggest that, compared
with optimal blood pressure, long-term hypertension (systolic ≥140 mmHg) roughly
doubles CKD incidence (relative risks ∼1.6–2.1)[8]. These effects may be stronger in
men than women, reflecting observed sex differences in CKD progression [8]. Given
the close interplay between hypertension and kidney function, effective blood
pressure control is a key strategy to prevent CKD onset and slow its progression.

The Global Burden of Disease (GBD) study provides comprehensive, comparable

estimates of disease burden worldwide, including CKD stratified by cause and risk
factor. GBD 2023 quantifies CKD burden by underlying etiology (type 1 and 2
diabetes, hypertension, glomerulonephritis, etc.) and by country, year, age, and sex[2].
Such data enable analysis of the global and regional CKD burden specifically
attributable to hypertension. In this way, GBD metrics can identify where
hypertensive CKD is most common and changing, and thereby inform targeted
prevention and resource planning.
Despite the mounting evidence, CKD has long been under-recognized in global health
policy. Notably, kidney disease is not listed among the five major NCDs in the WHO
2
targets (heart disease, stroke, cancer, chronic lung disease, diabetes), and fewer than half
of the countries have a national CKD strategy or recognize CKD as a health priority[3,9].
Epidemiological data are also incomplete: most countries lack routine CKD screening,
and many CKD cases go undiagnosed until late stages. Prior global analyses have not
reported the proportion of CKD burden due specifically to hypertension, nor have they
thoroughly examined sex-specific trends in hypertensive CKD. These gaps limit
precision prevention. For example, recent work shows CKD prevalence is ~30% higher
in women, whereas men are much more likely to receive dialysis or die from CKD,
underscoring the need to address gender disparities[2]. In short, there is a critical need for
updated global data on hypertension-attributable CKD and its sex differences to guide
policy and interventions.

The objectives of this study are to quantify the global burden of chronic kidney
disease attributable to hypertension from 2000 to 2023 using GBD 2023 data, with
attention to temporal trends and gender differences. Specifically, we aim to estimate
global incidence, prevalence, mortality, and disability-adjusted life years (DALYs);
characterize temporal trends, compare burdens between women and men to identify
gender-based disparities; and identify key evidence gaps and policy implications to
inform global kidney-health strategies. In preparation for this article, AI-assisted tools
were used per the TITAN Guidelines 2025[10].

Methods
Data Source and Study Design

This study is a descriptive ecological analysis of chronic kidney disease attributable to

hypertension (CKD-HTN) using annual estimates from the Global Burden of Disease 2023
study, accessed via the Institute for Health Metrics and Evaluation (IHME) GBD Results Tool.
The unit of analysis is the population (country-year and global aggregates), not individuals; all
analyses therefore use summary measures (age-standardized rates and counts). Because
exposure and outcome data are aggregated, relationships observed at the population level do
not necessarily reflect individual-level associations (ecological fallacy). Our objective is to
describe population-level burden and temporal trends in CKD attributable to hypertension
rather than to make causal inferences about individual risk. We examined annual data for the

3
period 2000–2023 at the aggregate (global) level; no individual-level data were used and all
analyses were performed on publicly available, de-identified estimates.

Data Extraction and Preparation

We downloaded the filtered GBD 2023 results CSV, which includes only records where the
cause was 'Chronic kidney disease due to hypertension,' the location was 'Global,' and the year
ranged from 2000 to 2023. The data was filtered directly in the GBD tool before downloading.
For overall trend analyses, we retained entries with sex = Both, and for sex-specific analyses,
we separately extracted records with sex = Male and sex = Female. Within each subset, we
selected two age categories: “All ages” to capture absolute counts (metric = Number) and
“Age-standardized” to capture standardized rates per 100,000 (metric = Rate) for four burden
measures: Deaths, Disability-Adjusted Life Years, Incidence, and Prevalence. We preserved all
associated 95% uncertainty interval bounds (lower and upper UIs) provided by IHME.

Variable Definitions

We defined deaths as the cause-specific number of fatalities and their corresponding age-
standardized death rate. DALYs represent the sum of years of life lost (YLLs) and years lived
with disability (YLDs) due to hypertensive CKD. Incidence denotes the number of new CKD-
HTN cases annually, and Prevalence indicates the total existing CKD-HTN cases each year;
both measures were analysed as absolute counts and age-standardized rates. Uncertainty
intervals reflect the 95% credible range around each estimate, accounting for model and data
input variability.

Statistical Analysis

Annual estimates of absolute counts and age-standardized rates are summarized in tables and
figures. Sex-stratified estimates are illustrated for males and females. We calculated the
percentage change from 2000 to 2023 for each measure using the formula

(Value2023 − Value2000)
%Δ = × 100
Value2000

Descriptive estimates are presented with 95% uncertainty intervals (UIs) as provided by the
source dataset. Temporal trends and statistically significant change-points were identified using
Joinpoint Trend Analysis Software v5.4.0 with log-linear models. Segment-specific annual
percent changes (APCs), 95% confidence intervals (CIs), and p-values are reported. Data
4
management and descriptive analyses were performed in Microsoft Excel (version 2512), and
figures and tables were generated using Excel’s charting tools.

Ethics and Reproducibility

Because all data are aggregated and publicly available, institutional review board approval
and participant consent were not required. To support transparency and reproducibility, we
retained the exact filtering criteria: cause, location, years, age category, sex, metric, and
measure. All methods adhere to GBD reporting guidelines by explicitly presenting point
estimates alongside uncertainty intervals.

5
Results

Annual data points (2000–2023) for global chronic kidney disease attributable to hypertension
were analysed across four core metrics: deaths, disability-adjusted life years, incidence, and
prevalence. All estimates are presented with 95% uncertainty intervals to reflect the range of
plausible values based on GBD modelling. Below, we describe the temporal trends, magnitude
of change, and the statistical uncertainty around these estimates.

Mortality Trends

Between 2000 and 2023 the annual number of CKD-HTN deaths increased from 189,423 (95%
UI 153,882.5–229,624.9) to 442,348 (95% UI 358,471.2–530,084.9), a 133.6% rise (Table 1).
The age-standardized death rate rose from 3.10 (95% UI 2.52–3.76) to 5.48 (95% UI 4.44–
6.57) per 100,000 (a 76.8% increase). The absolute width of the 95% UI for the rate increased
from 1.24 to 2.13 per 100,000 between 2000 and 2023. Joinpoint regression identified change-
points in 2017 (95% CI 2002–2018) and 2020 (95% CI 2014–2021); APCs were +2.43% (95%
CI 2.21–3.28; p = 0.0004) for 2000–2017, +1.74% (95% CI 1.11–2.46; p < 0.000001) for 2017–
2020, and +3.75% (95% CI 2.54–5.11; p < 0.000001) for 2020–2023, indicating statistically
significant increasing trends across all segments (Figure 1).

Table 1. Annual number of deaths and age-standardized death rates per 100,000 (CKD-HTN, Global, 2000–2023)

Year Deaths (N) Upper UI Lower UI Rate Rate Upper UI Rate Lower UI

2000 189423.1 229624.9 153882.5 3.101064 3.759212 2.519227

2005 227828.8 272829.4 190866.5 3.498383 4.189382 2.930815

2010 277235.5 329498.8 230427.3 3.981431 4.731994 3.30921

2015 332006.4 394102 282491.6 4.478422 5.316028 3.810519

2020 388053.4 462399 322835 4.943471 5.89057 4.112644

2023 442348 530084.9 358471.2 5.484223 6.571985 4.44432

Over the 23-year period, CKD-HTN deaths rose by 133,000 (from ~189K to ~442K), with age-standardized
mortality increasing by 76.8% (from 3.1 to 5.48 per 100,000), indicating a genuine rise in risk independent of
population aging.

6
Figure 1 Global age-standardized death rate of CKD attributable to hypertension, 2000–2023, with joinpoint regression
trends.

Burden of Disease (DALYs)

Between 2000 and 2023 the global number of DALYs for CKD attributable to hypertension
increased from 4,526,766 (95% UI 3,755,852–5,536,793) to 9,452,632 (95% UI 7,902,538–
11,135,353), a 108.8% rise (Table 2). The age-standardized DALY rate rose from 74.1 (95%
UI 61.49–90.64) to 117.19 (95% UI 97.98–138.06) per 100,000 (a 58.1% increase). Joinpoint
regression identified change-points at 2016 (95% CI 2007–2016) and 2019 (95% CI 2018–
2021); APCs were +1.93% (95% CI 1.89–2.08; p < 0.000001) for 2000–2016, +1.30% (95%
CI 0.98–1.82; p < 0.000001) for 2016–2019, and +2.76% (95% CI 2.39–3.57; p < 0.000001)
for 2019–2023 (Figure 2).

7
Table 2. Annual DALYs and age-standardized DALY rates per 100,000 (CKD-HTN, Global, 2000–
2023)

Year DALYs (N) Upper UI Lower Rate Rate Upper UI Rate Lower UI
UI

2000 4526766 5536793 3755852 74.10814 90.6434 61.48744

2005 5353555 6312466 4516213 82.20551 96.9299 69.34787

2010 6295214 7540068 5292830 90.40674 108.2843 76.01133

2015 7381696 8721768 6343230 99.57143 117.6476 85.5636

2020 8441729 9961975 7126260 107.5405 126.9071 90.7825

2023 9452632 11135353 7902537 117.1936 138.0559 97.97553

Global age-standardized DALY rates rose by 58.1% (74.1 → 117.19 per 100,000), reflecting mounting years lost
to premature death and disability due to hypertensive CKD.

Figure 2 Global age-standardized DALY rate of CKD attributable to hypertension, 2000–2023, with joinpoint regression
trends.
8
Incidence Dynamics

New cases of CKD attributable to hypertension increased from 1,208,637 (95% UI: 1,121,250–
1,316,525) in 2000 to 2,259,074 (95% UI: 2,096,706–2,452,550) in 2023, an 86.9% rise in
absolute incidence (Table 3). The age-standardized incidence rate rose from 19.78 (95% UI:
18.36–21.55) to 28.00 (95% UI: 26.00–30.41) per 100,000, a 41.5% increase; non-overlapping
uncertainty intervals between 2000 and 2023 indicate this change is statistically significant.
Trend analysis shows the rate increased at an average annual percent change (APC) of roughly
+1.7% from 2000–2015, accelerating to +2.3% from 2015–2023. Joinpoint regression (2000–
2023) identified two significant inflection points in 2010 and 2016 (2016 CI: 2015–2017),
yielding three segments with APCs of +1.31% (95% CI 1.30–1.32%) for 2000–2010, +1.61%
(95% CI 1.59–1.62%) for 2010–2016, and +1.76% (95% CI 1.74–1.77%) for 2016–2023 as
shown in figure 3 (all p < 0.000001). These results indicate a consistent acceleration in
incidence over time, with the steepest increase after 2016, a pattern that may reflect changes in
population risk (for example, rising hypertension prevalence and aging), improved
detection/reporting, or health-system factors.

These findings imply worsening hypertension control or other risk factor dynamics that have
translated into more individuals developing CKD each year.

Table 3. Annual new cases and age-standardized incidence rates per 100,000 (CKD-HTN, Global, 2000–2023)

Year Incidence Upper Lower Rate Rate Upper Rate Lower

(N) UI UI UI UI

2000 1208637 1316525 1121250 19.78672 21.55297 18.3561

2005 1374711 1494092 1279317 21.10911 22.94226 19.64432

2010 1569530 1700680 1461934 22.54031 24.42378 20.9951

2015 1809333 1956965 1685111 24.40603 26.39743 22.7304

2020 2086508 2265635 1933425 26.58034 28.86226 24.63019

2023 2259074 2452550 2096706 28.00796 30.40667 25.99492

9
New CKD-HTN cases rose by 86.9% in absolute terms (1.21M → 2.26M) and 41.5% in age-standardized
incidence rate, suggesting escalating hypertensive kidney injury worldwide.

Figure 3 Global age-standardized incidence rate of CKD attributable to hypertension, 2000–2023, with joinpoint
regression trends.

Prevalence Dynamics

The total number of people living with CKD attributable to hypertension increased from
30,602,155 (95% UI: 28,694,767–32,574,663) in 2000 to 55,648,458 (95% UI: 52,329,541–
59,338,144) in 2023, an 81.8% rise (Table 4). Age-standardized prevalence rose from 500.99
(95% UI: 469.76–533.28) to 689.92 (95% UI: 648.78–735.67) per 100,000—a 37.7%
increase—with non-overlapping UIs between 2000 and 2023 denoting statistical significance.
Joinpoint regression of prevalence (2000–2023) identified four significant inflection points in
2005, 2010, 2016 (2016 CI: 2015–2017) and 2021, producing five trend segments. Prevalence
increased in every segment with APCs of +1.35%10(95% CI 1.33–1.37) for 2000–2005, +1.16%
(95% CI 1.14–1.18) for 2005–2010, +1.36% (95% CI 1.34–1.38) for 2010–2016, +1.50% (95%
CI 1.48–1.53) for 2016–2021, and +1.99% (95% CI 1.94–2.04) for 2021–2023 as shown in
Figure 4 (all p < 0.000001). The overall pattern, characterized by a steady and nearly linear
accumulation of prevalent cases with an accelerated increase after 2021, likely reflects
demographic ageing and longer disease duration, with improved survival among affected
individuals, and may also be influenced by changes in detection, case mix, or health system
factors.

Table 4. Annual prevalent cases and age-standardized prevalence rates per 100,000 (CKD-HTN, Global, 2000–2023)

Year Prevalence Upper UI Lower UI Rate Rate Upper Rate Lower

(N) UI UI

2000 30602155 32574662 28694767 500.991 533.2831 469.7649

2005 34887496 37086529 32781272 535.7085 569.4753 503.3667

2010 39531166 42081059 37136519 567.7145 604.334 533.3245

2015 45027905 47878606 42306955 607.3798 645.8328 570.677

2020 51271214 54568492 48248588 653.1517 695.1562 614.646

2023 55648458 59338144 52329541 689.9287 735.6734 648.7808

The number of individuals living with CKD due to hypertension climbed by 25.05 million (+81.8%), with age-
standardized prevalence up 37.7%, highlighting the growing chronic disease burden.

11
Figure 4 Global age-standardized prevalence rate of CKD attributable to hypertension, 2000–2023, with joinpoint
regression trends.

Table 5: Comparative Overview

Metric 2000 Value 2023 Value (Rate) Absolute Change Rate Change
(Rate) (%) (%)

Deaths 189423 (3.1) 442348 (5.48) +133.6% +76.8%

DALYs 4526766 (74.1) 9452632 (117.19) +108.8% +58.1%

Incidence 1208637 2259074 (28) +86.9% +41.5%

(19.78)

Prevalence 30602155 55648458 +81.8% +37.7%

(500.99) (689.92)

12
All four core metrics- mortality, DALYs, incidence, and prevalence show statistically
significant upward trends between 2000 and 2023 (Table 5). Over this period, the global burden
of chronic kidney disease attributable to hypertension increased substantially, with mortality
showing the largest relative rise, suggesting either greater lethality or increased detection of
more severe disease despite medical advances.

Deaths (Rate)
6
Age-standardized death rate (per 100,000)

Male Female

Figure 5. Gender-Specific Trends in Age-Standardized Mortality Rates from Hypertensive

CKD (2000–2023)

At every time point, age‐standardized death rates are higher in males than in females. In 2000,
the male rate was 3.36 versus 2.82 per 100,000 in females (∆ = 0.54). By 2023 the difference
drop to 0.42 (5.69 vs. 5.27). While the age-standardized death rate gap between males and
females has narrowed, with the absolute difference decreasing from 0.54 in 2000 to 0.42, males
continue to experience higher mortality rates, indicating a persistent but reduced sex disparity
in death rates over time (Figure 5).

13
 DALY (Rate)
140

120
Age-standardized DALY rate (per 100,000)

100

80

60

40

20

Male Female

Figure 6. Gender Differences in Age-Standardized DALY Rates from Hypertensive CKD

(2000–2023)

Male DALY rates start markedly above female rates at 84.32 vs. 63.74 per 100,000 (∆ = 20.58)
in 2000 and diverge further to 128.58 vs. 105.72 (∆ = 22.86) by 2023. This growing difference
suggests that men experience both higher premature mortality (YLLs) and/or greater years
lived with disability (YLDs) from hypertensive CKD (Figure 6).

Incidence (Rate)
35

30
Age-standardized Incidence rate (per 100,000)

25

20

15

10

Male Female
14
Figure 7. Gender-Specific Trends in Age-Standardized Incidence Rates from Hypertensive
CKD (2000–2023)

Women consistently show slightly higher incidence rates of chronic kidney disease due to
hypertension, with 17.75 vs. 21.85 per 100,000 in 2000 (∆ = 4.1) and 25.77 vs. 30.26 in 2023
(∆ = 4.49) for males and females respectively (Figure 7). This trend reflects a persistent, albeit
marginal, widening of the gender gap in the incidence of CKD related to hypertension over
time

Prevalence (Rate)
800
Age-standardized Prevalence rate (per 100,000)

700

600

500

400

300

200

100

Male Female

Figure 8. Gender-Specific Trends in Age-Standardized Prevalence Rates from Hypertensive

CKD (2000–2023)

Similarly, female prevalence rates exceed male rates by a small margin throughout most of the
period. Prevalence rate was at 537.49 for females while 465.02 for males in 2000 (Figure 8).
The difference rose from 72.47 to 83.3216 in 2023 (731.75 for females, 648.428 for males).

Overall, these patterns highlight a complex gender difference in the burden of CKD due to
hypertension. While incidence and prevalence rates higher in females, indicating a greater
presence of the disease among women, mortality
15 and DALYs remain significantly higher in
men. This suggests that despite a lower prevalence and incidence in males, the disease burden
is more severe in this group, likely due to higher fatality rates and greater loss of healthy life
years. These findings underscore a shifting but still unequal impact of CKD-HTN across
genders, with women experiencing more cases but men suffering a greater overall disease
burden in terms of mortality and disability.

Discussion

Our analysis of GBD 2023 data (2000–2023) shows a marked rise in the global burden of CKD
attributable to hypertension. Globally, the number of annual CKD-HTN deaths more than
doubled (+133.6%), with the age-standardized mortality rate rising by about 76.8%. Similarly,
CKD-HTN DALYs roughly doubled (+108.6%) and the age-standardized DALY rate
increased by 58.1%. Age-standardized incidence and prevalence rates also climbed
substantially (41.5% and 37.7% increases, respectively). These trends indicate that CKD due
to hypertension is a rapidly growing cause of global morbidity and mortality.

Gender Disparities in CKD Outcomes

A striking finding in CKD epidemiology is that men experience worse outcomes than women,
despite having significantly lower disease incidence and prevalence. Our data shows that men
have higher mortality and DALYs. This pattern has biological and behavioral explanations:

• Biological Factors: Hormonal differences appear important. Estrogen may protect

kidney function, whereas testosterone (and other androgen-related effects) can
accelerate injury[11]. Consistent with this, longitudinal studies find that men have a
faster decline in glomerular filtration over time. In one meta-analysis, for example,
men with hypertension progressed to CKD/ESRD more rapidly than women. These
intrinsic differences mean that for the same level of initial damage, a man’s kidney
may fail sooner than a woman’s[8].

• Healthcare Utilization and Behavior: Men often engage less with health services
than women. Numerous surveys (e.g., CDC data) show men seek preventive care and
16
 screening far less frequently[12]. In CKD specifically, primary-care audits find that
women are more likely to receive a CKD diagnosis, whereas men are underdiagnosed
until very late[13]. In one UK study, for instance, women had higher recorded CKD
prevalence, but male patients were more likely to progress to kidney failure[13]. This
suggests that many men with CKD are missed until the disease is severe.

• Adherence and Risk Profile: Men also tend to have poorer health behaviors on
average. Smoking, uncontrolled blood pressure, and dietary factors (e.g., high salt) are
often more prevalent among men, compounding kidney damage. Studies have noted
that men are less likely to adhere to chronic medication regimens and lifestyle changes
compared to women. Even when diagnosed, men may be less likely to attend regular
follow-up or comply with treatment plans. These behavioral gaps can amplify the
impact of CKD: a man with undiagnosed hypertension or untreated CKD will
accumulate damage faster than a woman in a similar situation.

In summary, sex differences in CKD cannot be explained by biology alone. Social and
health-system factors play a major role. Men’s lower use of preventive care leads to
later diagnosis and less timely management, while women’s higher diagnosis rates
(even of mild CKD) suggest greater healthcare engagement[13]. Clinicians and public
health planners must therefore consider these dynamics: men may need targeted
screening strategies and adherence support, whereas women’s CKD may be
overdiagnosed relative to men (a point of some debate).

Factors likely confounding trends

CKD is often silent until advanced, and many cases are only identified when patients present
with complications. In regions with better diagnostics and awareness, increased screening (for
example, among people with hypertension or diabetes) has discovered previously hidden
cases[11,12]. Indeed, global prevalence (>10%) is thought to be underestimated because of a lack
of routine early detection programs[3,13]. Thus, rising CKD rates may partly represent “catch-
up” from improved surveillance rather than solely a biological explosion of disease.

17
 • Improved Detection vs. True Risk: Expanded screening, registry building and
awareness campaigns in many countries have uncovered cases that would previously
go unreported[11]. For instance, awareness initiatives (such as those by the Netherlands
Kidney Foundation) are known to increase CKD detection rates[11]. At the same time,
demographic shifts (aging populations) and growing diabetes/hypertension epidemics
are driving a real rise in CKD. Separating these forces is challenging.
• Underdiagnosis in Low-Resource Settings: In low-income or low-SDI regions, CKD
screening is sparse or absent. Surveys suggest that the majority of CKD cases remain
undiagnosed in these settings[3,12]. For example, late-stage CKD often goes
unrecognized until patients reach kidney failure. Published estimates note that CKD
prevalence is likely much higher than reported, simply due to limited early testing[3]. In
short, case ascertainment bias can inflate incidence/prevalence trends in areas with
better health systems while suppressing them elsewhere.
• Heterogeneous Data and Diagnostic Criteria: Differences in how CKD is defined or
coded can also affect trends. Adoption of newer equations (CKD-EPI vs MDRD) or
differing thresholds across countries means that some increases may reflect changing
case definitions. Delays in data collection and reporting further complicate
interpretation.

Taken together, these points mean that observed increases in CKD rates must be interpreted
cautiously. Some rise is no doubt real (driven by risk factors), but a substantial part could
be artefactual, an “iceberg” of previously invisible disease coming to light[3,11].

Comparison with previous studies

While several previous analyses, including GBD-based studies, report a greater

overall CKD-HTN burden worldwide, especially among men, our findings reveal a
more nuanced, sex-discordant pattern: incidence and prevalence were significantly
higher in females, whereas mortality and DALYs were disproportionately higher in
males. Chen et al. (GBD 2019 data) reported ~125% rise in CKD-HTN DALYs from
1990 to 2019, mirroring our observation of large absolute increases. Likewise, Liu et
al. reported that the global age-standardized incidence (ASIR) and mortality (ASDR)
rates for CKD due to hypertension increased markedly between 1990 and 2019[7,14]. Many
prior studies examine all CKD rather than CKD-HTN; nevertheless, their patterns are
consistent in terms of DALYs and death18rates. The 2021 GBD CKD analysis
documented a 33% rise in age-standardized CKD prevalence from 1990 to 2017 and
reported a higher overall CKD burden in men across most age groups; this aligns with
the global upward trend but contrasts with our sex-specific pattern[3,12].

In summary, our findings reinforce the established observation that the global burden of CKD
is increasing and that hypertension remains a major contributing factor, while also revealing
a distinct sex-specific pattern. The significantly higher incidence and prevalence of CKD-
HTN among women indicate a greater contribution of females to the expanding population
living with hypertensive CKD, a dimension that has received comparatively limited emphasis
in prior literature. At the same time, the higher mortality and DALY rates among men are
consistent with previous reports showing that, despite higher CKD prevalence in women,
disease progression and fatal outcomes tend to be more pronounced in men[12]. Collectively,
these findings suggest that sex differences in CKD-HTN are characterized not only by
disparities in disease severity and outcomes, but also by differences in disease occurrence,
underscoring the importance of sex-disaggregated interpretation of CKD burden estimates.

Public Health and Policy Implications

The accelerating CKD-HTN burden carries urgent public health implications. First, it
underscores the need for stronger hypertension prevention and control globally. Inadequate
blood-pressure management is a key modifiable risk factor for CKD; our findings suggest
that improving hypertension diagnosis and treatment could slow the rise of CKD-
HTN. Comprehensive policies are needed: experts recommend expanded CKD
screening in high-risk populations (especially men and older adults), education on kidney-
healthy lifestyles, and tighter control of SBP and other metabolic risk factors[12,15]. For
example, Luyckx et al. note that merely addressing diabetes and cardiovascular risk
is insufficient for CKD specific, kidney-focused interventions are required[16]. Our
data also highlight global disparities: low-SDI regions showed persistently high
CKD-HTN mortality in prior analyses, suggesting resources must be prioritized
there[7,15]. On the health system side, Chen et al. found that improving socioeconomic
conditions and healthcare access (e.g., physician density) would significantly reduce
CKD-HTN burden[14]. In practice, this means investing in primary care, ensuring
affordable antihypertensive medication, and integrating kidney function monitoring into
routine care. As kidney experts emphasize, implementing early-detection programs
19
and public education campaigns could substantially curb CKD morbidity and
mortality[3,12].

Strengths and Limitations

A key strength of this analysis is its use of the GBD 2023 dataset, which provides
standardized, comparable estimates across 204 countries. This allows a truly global
perspective on CKD-HTN trends. However, GBD results have inherent limitations.
CKD due to hypertension must be inferred from available data and modeling, which
may misclassify some cases. Countries vary in how well they capture CKD and its etiology;
under-registration of CKD in low-resource settings could bias estimates. Additionally,
the GBD model relies on covariates and predictive algorithms, potentially
underestimating uncertainty in areas with sparse data. A general limitation of GBD-
based statistical interpretation is that treating non-overlap of 95% uncertainty
intervals between time points as evidence of change is a heuristic rather than a formal
hypothesis test. We also focused on the period 2000–2023; earlier trends (e.g., 1990s) or
very recent changes (post-2023) are not addressed. Finally, our findings reflect associations
and cannot prove causality; for example, the rise in CKD-HTN may partly reflect better
diagnosis of CKD rather than a true increase in disease incidence. Nevertheless, the
consistency with prior GBD analyses and the magnitude of the trends lend confidence
to the conclusion that CKD due to hypertension is a growing global health challenge.

Future Directions

Given these trends, further research should aim to elucidate the drivers of rising CKD-
HTN and test interventions to reverse it. Longitudinal studies could examine how changes
in obesity, salt intake, diabetes prevalence, and hypertension control policies influence
CKD-HTN rates. Investigations into why men have worse outcomes are also needed; for
example, studies could explore gender differences in healthcare access or biological
susceptibility. At the system level, modeling the impact of intensified blood pressure
programs on future CKD burden would inform policy. International experts have called
for CKD to become an explicit global health priority[3]. In line with that, multicountry
trials of enhanced hypertension management in high-risk populations could demonstrate
scalability. Finally, more detailed regional and subnational GBD analyses would help
target resources: for instance, mapping CKD-HTN
20 hotspots and relating them to risk
factor profiles or health infrastructure (as done for other diseases) would guide
policymakers[7,14]. In sum, future work should combine epidemiological surveillance
with interventional research to break the trajectory of CKD-HTN.

Conclusion

The global burden of chronic kidney disease attributable to hypertension has risen
dramatically from 2000 to 2023, in both absolute and age-standardized terms.
Notably, while incidence and prevalence are higher in females, mortality and DALY
remain lower compared to males, indicating a complex gender dynamic in the disease
burden. The sharp increases in deaths, DALYs, incidence, and prevalence underscore
an urgent need for action. These findings reinforce that CKD-HTN is a major and
growing public health problem worldwide. Policymakers and clinicians must
prioritize blood pressure control and CKD prevention to stem this trend. Without
targeted efforts, kidney disease, the third fastest-growing cause of death globally, will
continue to escalate. Our study adds to the evidence base by providing up-to-date global
estimates through 2023, forming a compelling case for intensified global CKD and
hypertension initiatives.

Keywords

Hypertensive chronic kidney disease, Global Burden of Disease (GBD), Age-

standardized rates, Sex disparities, Epidemiological trends, Noncommunicable
diseases, Disability-adjusted life years (DALYs), Public health surveillance

Abbreviations

CKD: Chronic Kidney Disease, CKD-HTN: Chronic Kidney Disease attributable to

Hypertension, GBD: Global Burden of Disease, IHME: Institute for Health Metrics and
Evaluation, DALY / DALYs: Disability-Adjusted Life Year(s), YLL / YLLs: Year(s) of Life
Lost, YLD / YLDs: Year(s) Lived with Disability, UI / UIs: Uncertainty Interval(s), APC:
Annual Percent Change, NCD / NCDs: Noncommunicable
21 Disease(s), ESRD: End-Stage
Renal Disease, SDI: Socio-demographic Index, SBP: Systolic Blood Pressure

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