Presentation Summary

Writen by Jasna Trbojevic-Stankovic
Reviewed by Mehmet Sukru Sever

The world Bank classifies economies into 3 groups: low income (LIC), middle income (MIC), and high income (HIC) countries. In the low income states, gross national income (GNI) per capita is less than 1000 USD, while this figure is more than 12.000 USD in HIC. In the MIC group (which is further divided into lower and upper MIC) GNI is between these limits.[1]
Due to low availability of effective therapies and resource limitations, early preventive and therapeutic measures in low-income countries (LIC) and lower-middle-income countries (LMIC) are essential. Spectrum, extent, diagnosis, treatment, and outcome show considerable variations between HIC and LMIC. Only one-third of LIC are able to measure serum creatinine and none to access estimated glomerular filtration rate (eGFR) or quantify proteinuria. The capability to monitor diabetes mellitus is substandard and pathology services are not always available.[2] Moreover, there is a strong connection between the number of nephrologists, dialysis facilities, and a country’s gross domestic product[3].

Acute kidney injury
Acute kidney injury (AKI) occurs in around 13.3 million people per year, 85% of which live in a developing world[4]. The world incidence of AKI, defined according to the Kidney Disease Improving Global Outcomes (KDIGO) criteria, is 21.6% in adults and 33.7% in children, with 1 in 5 adults and 1 in 3 children experiencing AKI during a hospital episode of care, with geographic and economic variations[5].
The demography and etiology of AKI dramatically differ between HIC, LIC and LMIC. In HIC, it mostly occurs in elderly intensive care unit (ICU) patients with multiple organ failure and is commonly associated with sepsis and complex surgery. Comparatively, in LMIC, AKI mostly occurs in rural area hospitals in young and otherwise healthy patients[6], and it it is mostly community-acquired. Furthermore, the most common etiologies in LMIC include infections and tropical diseases which may include not only sepsis or surgery-related infections and diarrhoeal illness, HIV/AIDS, leptospirosis, malaria[7], but also toxins, including snake venom, as well as inadvertent use of drugs[6][8].
The mortality of patients in LIC and LMIC and non-recovery of renal function is higher due to lack of ICUs and access to acute dialysis[9,10]. For example, the mortality rate of AKI in Ugandan sepsis patients was shown to be 100%[11]. The treatment of AKI cases is rather expensive in HIC whereas it is inexpensive, at least in early stages, and easily preventable in LIC an LMIC.[4]There are several prevention measures in LIC and LMIC such as improving infrastructure for drinking water and sanitation, educating all parties about avoiding toxic medications and herbs, improving obstetric and perinatal care, as well as educating general practitioners (GP), nurses and non-health professionals. The treatment actions include implementing management algorithms for intensive and intermediate care, resolving mild-to-moderate AKI via rapid fluid resuscitation, vasopressors and antibiotics, training in peritoneal dialysis (PD) provision and catheter insertion, and creating referral centres for intermittent haemodialysis (IHD) for patients with contraindicated PD. As AKI in LIC and LMIC is preventable, International Society of Nephrology (ISN) initiated ″0by25″ initiative that targets to eliminate preventable mortality cases from AKI by 2025[4].

Chronic kidney disease
It has been estimated that the prevalence of chronic kidney disease (CKD) in LIC and LMIC is higher than in HIC due to rapid urbanization that results in unhealthy lifestyle. In addition to that, non-communicable disease (NCD) cases have been significantly increasing due to number of factors, especially hypertension (HT) and diabetes mellitus (DM). The summary of several community-based studies showed considerable variations in estimated prevalence between regions and countries, from 4.7% to 29.9%[12], while one analysis indicated that there were over 497 million adults in the world that were suffering from CKD, the majority of whom live in LIC and LMIC.[13]
CKD includes NCD, of which particularly DM, types I and II, HT and obesity, then communicable and infectious diseases and environmental and occupational exposures.[12]It has been estimated that over 8% of world population has DM and 75% of them live in LIC and LMIC. Delayed diagnosis and poor management of DM and HT in LIC and LMIC can lead to CKD and consequently is a risk factor for end-stage kidney disease (ESKD). Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARBs) slow progression rate for both early and late stages of CKD.[14, 15], but only 50% of patients with DM will undergo simple screening for CKD in sub-Saharan African countries and only less than 20% of CKD patients in Nigeria were prescribed ACEi and ARBs.[16]
Capacity for provision of renal replacement therapy
All modalities of renal replacement therapy (RRT) are possible in HIC and PD is used the least. Some treatment modalities are deficient in LIC, but few are almost fully available (Figure 1). Unfortunately, only 5% of the population of LIC can reach HD despite it being available.[2].

Figure 1. Use of RRT by modality in LIC and LMIC. The most frequently used treatment is IHD while PD is not used regularly.[11].

The measure that could decrease the extent of this problem may be increasing public awareness and GPs education about DM, HT and CKD. The availability of ACEi and ARBs in primary care should be ensured to delay the progression of ESKD. Deceased-donor registries should be developed for activating transplant programmes and surgeons, and also nephrologists should be educated on transplantation in order to improve overall survival. Additionally, more frequent use of PD could be achieved by decreasing the cost of solutions. Should all these measures fail and the patient cannot afford the dialysis, palliative programmes need to be created.


2. Htay H, Alrukhaimi M, Ashuntantang GE, et al. Global access of patients with kidney disease to health technologies and medications: findings from the Global Kidney Health Atlas project. Kidney Int Suppl (2011) 2018;8(2):64-73

3. Lewington AJ, Cerda J, Mehta RL. Raising awareness of acute kidney injury: a global perspective of a silent killer. Kidney Int 2013;84(3):457-467

4. Mehta RL, Cerda J, Burdmann EA, et al. International Society of Nephrology’s 0by25 initiative for acute kidney injury (zero preventable deaths by 2025): a human rights case for nephrology. Lancet 2015;385(9987):2616-2643

5. Susantitaphong P, Cruz DN, Cerda J, et al. World incidence of AKI: a meta-analysis. Clin J Am Soc Nephrol 2013;8(9):1482-1493

6. Cerda J, Mohan S, Garcia-Garcia G, et al. Acute Kidney Injury Recognition in Low- and Middle-Income Countries. Kidney Int Rep 2017;2(4):530-543

7. Naicker S, Aboud O, Gharbi MB. Epidemiology of acute kidney injury in Africa. Semin Nephrol 2008;28(4):348-353

8. Luyckx VA, Naicker S. Acute kidney injury associated with the use of traditional medicines. Nat Clin Pract Nephrol 2008;4(12):664-671

9. Bouchard J, Acharya A, Cerda J, et al. A Prospective International Multicenter Study of AKI in the Intensive Care Unit. Clin J Am Soc Nephrol 2015;10(8):1324-1331

10. Anand S, Shivashankar R, Ali MK, et al. Prevalence of chronic kidney disease in two major Indian cities and projections for associated cardiovascular disease. Kidney Int 2015;88(1):178-185

11. Prabhakaran D, Anand S, Watkins DA et al. Cardiovascular, Respiratory, and Related Disorders. Disease Control Priorities,. third, ed. Washington, DC,: World Bank,; 2017.

12. Stanifer JW, Muiru A, Jafar TH, et al. Chronic kidney disease in low- and middle-income countries. Nephrol Dial Transplant 2016;31(6):868-874

13. Mills KT, Xu Y, Zhang W, et al. A systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. Kidney Int 2015;88(5):950-957

14. Kshirsagar AV, Joy MS, Hogan SL, et al. Effect of ACE inhibitors in diabetic and nondiabetic chronic renal disease: a systematic overview of randomized placebo-controlled trials. Am J Kidney Dis 2000;35(4):695-707

15. Hou FF, Zhang X, Zhang GH, et al. Efficacy and safety of benazepril for advanced chronic renal insufficiency. N Engl J Med 2006;354(2):131-140

16. Agaba EI, Puepet FH, Ugoya SO, et al. Chronic kidney disease screening and renoprotection in type 2 diabetes. Ann Afr Med 2009;8(1):52-54

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