Chronic kidney disease (CKD) is one of the most significant and growing public health challenges of the 21st century, yet it remains underrecognized and undertreated — particularly in the regions where its impact is most severe. Data published in The Lancet in 2020 by Bikbov and colleagues, as part of the Global Burden of Disease study, estimated that more than 697 million individuals were living with CKD worldwide in 2017, with the highest age-standardized prevalence and mortality rates recorded in sub-Saharan Africa and Oceania — regions also among the most under-resourced in healthcare infrastructure.
CKD patients, including those without diabetes, and are becoming increasingly available as generic production expands. At the policy level, the inclusion of CKD in global non-communicable disease frameworks and the growing recognition by the WHO and UN of kidney health as part of universal health coverage provide structural foundations for national action. The ISN actively contributes nephrology expertise and GKHA evidence to these international deliberations.
Emerging Tools and Interventions Offering Promise for LMICs
- Point-of-care urine dipstick and handheld creatinine analyzers enabling field-based CKD detection
- Telemedicine and digital health platforms extending nephrology specialist reach to rural populations
- SGLT2 inhibitors demonstrating kidney-protective effects across CKD populations, with growing generic availability
- Task-shifting models training community health workers to conduct kidney screening and follow-up
- WHO and UN frameworks for universal health coverage providing structural support for CKD inclusion
- International research collaborations generating LMIC-specific evidence to guide local clinical practice
Conclusion: Evidence, Equity, and the Path Forward
Chronic kidney disease in low- and middle-income countries represents one of the defining health equity challenges of the current era. The data are unambiguous: hundreds of millions of people are affected, the burden falls most heavily on those with the least access to care, and the human cost — measured in preventable deaths, lost productivity, and needless suffering — is enormous. The International Society of Nephrology has demonstrated, through the Global Kidney Health Atlas, the Saving Young Lives program, and the 0by25 AKI initiative, that meaningful progress is achievable through coordinated, evidence-based, and equity-driven action.
The ISN’s sustained commitment to global kidney health reflects the understanding that nephrology, as a discipline, has a responsibility extending beyond individual patient care to encompass advocacy, education, and systemic change. Reversing the trajectory of CKD in LMICs will require sustained investment, political will, and the international scientific collaboration that the ISN exemplifies. The path is demanding, but clearly defined — and the stakes, measured in millions of preventable deaths, could not be higher.
For the International Society of Nephrology, these figures represent a humanitarian imperative. The ISN has consistently worked to document, understand, and address kidney health disparities across income groups and geographies. This article examines the multifaceted burden of CKD in low- and middle-income countries (LMICs), the systemic barriers that perpetuate it, and the evidence-based strategies that offer a path toward more equitable kidney care.
Understanding Chronic Kidney Disease: A Brief Clinical Overview
Chronic kidney disease is defined as the progressive loss of kidney function lasting three months or more. The kidneys filter metabolic waste from the blood, regulate fluid and electrolyte balance, control blood pressure via the renin-angiotensin system, and produce erythropoietin to support red blood cell production. When this function declines — due to diabetes, hypertension, glomerulonephritis, or other causes — these processes are progressively impaired. CKD is classified from stage G1 to G5 using estimated glomerular filtration rate (eGFR). At stage G5, known as end-stage renal disease (ESRD), the kidneys can no longer sustain life without dialysis or kidney transplantation.
CKD is often insidious: it may remain asymptomatic for years, advancing silently until a significant proportion of kidney function is irreversibly lost. This makes early screening and detection critically important — and it is precisely here that resource-limited settings face their greatest challenges.
CKD Staging and Clinical Milestones
| CKD Stage | eGFR (mL/min/1.73m²) | Description | Clinical Action |
|---|---|---|---|
| G1 | ≥ 90 | Normal or high | Risk factor monitoring, lifestyle intervention |
| G2 | 60–89 | Mildly decreased | Evaluate and treat underlying causes |
| G3a | 45–59 | Mildly to moderately decreased | Nephrology referral recommended |
| G3b | 30–44 | Moderately to severely decreased | CKD complication management |
| G4 | 15–29 | Severely decreased | Preparation for kidney replacement therapy |
| G5 | < 15 | Kidney failure (ESRD) | Dialysis or transplantation required |
The Epidemiological Landscape in Low- and Middle-Income Countries
The epidemiology of CKD in LMICs is shaped by compounding risk factors that differ substantially from those seen in high-income countries. Diabetic nephropathy and hypertensive kidney disease remain the leading causes globally, but their management in resource-limited settings is frequently inadequate due to fragmented primary care, limited availability of essential medicines, and insufficient patient education. In many sub-Saharan African nations, untreated or poorly controlled hypertension affects over half of the adult hypertensive population, while type 2 diabetes mellitus is rising rapidly as urbanization and lifestyle change accelerate across LMICs.
Compounding these factors are causes more uniquely prevalent in tropical regions: endemic infections such as malaria, HIV, hepatitis B and C, and schistosomiasis that directly impair kidney function or trigger immune-mediated glomerulonephritis. Recurrent episodes of acute kidney injury (AKI) — from dehydration, sepsis, or nephrotoxic traditional remedies — further accelerate progression in populations with limited access to kidney monitoring or specialist follow-up.
Key Risk Factors for Accelerated CKD Progression in LMICs
- Uncontrolled or untreated hypertension, affecting the majority of hypertensive individuals in many LMICs
- Poorly managed type 2 diabetes mellitus, with limited access to blood glucose monitoring and insulin
- Recurrent acute kidney injury episodes linked to infectious diseases, dehydration, and sepsis
- Endemic infections including HIV, malaria, hepatitis B and C, and schistosomiasis
- Use of nephrotoxic herbal remedies and unregulated analgesics without medical supervision
- Limited access to nephrology specialists, particularly in rural and peri-urban areas
- Insufficient laboratory infrastructure for early kidney function testing
The ISN Global Kidney Health Atlas: Mapping the Disparities
One of the most significant contributions of the International Society of Nephrology to global nephrology policy is the Global Kidney Health Atlas (GKHA), first published in Kidney International Supplements in 2017 and updated in subsequent editions. Covering more than 160 countries, the GKHA is the most comprehensive mapping exercise ever conducted of kidney care capacity, documenting the distribution of nephrology workforce, dialysis services, transplantation programs, and CKD policy frameworks worldwide. Its findings revealed stark disparities: while many high-income nations have more than 30 nephrologists per million population, several low-income African countries have fewer than one — meaning entire national populations may be served by only a handful of specialists.
For the ISN, the GKHA functions not merely as a research document but as a policy instrument. By quantifying gaps across systems and geographies, it enables governments, international organizations, and development funders to allocate resources strategically. ISN draws on GKHA data to guide its educational programs, advocacy, and capacity-building work in underserved regions.
| Resource | High-Income Countries | Upper-Middle-Income | Low-Income Countries |
|---|---|---|---|
| Nephrologists per million population | > 30 | 5–15 | < 1 |
| Access to hemodialysis | Widely available | Partially available | Severely limited |
| Kidney transplantation programs | Well established | Limited capacity | Rarely available |
| National CKD policy frameworks | Majority have formal policies | Variable | Most lack formal policies |
| Urinary albumin testing availability | Routine | Partially available | Often unavailable |
Screening in Resource-Limited Settings: Finding Kidney Disease Before It Is Too Late
Because early CKD is frequently asymptomatic, population-level screening is the most effective strategy for identifying at-risk individuals before irreversible damage occurs. Two biomarkers anchor contemporary CKD screening: the urinary albumin-to-creatinine ratio (uACR), which detects early glomerular damage often years before eGFR declines, and the estimated glomerular filtration rate itself. When albuminuria is identified in a person with diabetes or hypertension, timely intervention with renin-angiotensin system blockade — ACE inhibitors or ARBs — can slow or halt CKD progression significantly.
Deploying these tools at scale in LMICs presents real challenges where laboratory infrastructure is minimal and nephrology-trained staff are scarce. The ISN has supported the development of community-based screening models adapted for community health worker deployment in rural settings. The ISN-supported Saving Young Lives program, documented in NDT Plus and the Clinical Journal of the American Society of Nephrology, demonstrated that point-of-care dipstick urine testing and basic blood pressure measurement can effectively identify individuals requiring further clinical evaluation across sub-Saharan Africa and Asia.
Core Components of Effective CKD Screening in LMICs
- Urinary albumin-to-creatinine ratio (uACR) testing to detect early glomerular damage
- Estimated glomerular filtration rate (eGFR) measurement using serum creatinine
- Blood pressure assessment to identify hypertensive kidney disease risk
- Point-of-care urine dipstick testing deployable by community health workers
- Structured referral pathways linking community screening to nephrology services
- Patient education on CKD risk factors and the importance of follow-up
Acute Kidney Injury in LMICs: The Preventable Catastrophe
Acute kidney injury (AKI) — a sudden, often dramatic decline in kidney function developing over hours to days — kills hundreds of thousands of people each year in LMICs who could be saved with timely, basic intervention. Unlike CKD’s slow trajectory, AKI is frequently reversible, yet the two conditions are intimately linked: each AKI episode raises the risk of subsequent CKD and accelerates progression in those with pre-existing kidney disease. In high-income settings, most AKI patients survive through intravenous fluid resuscitation, infection control, and, when necessary, temporary dialysis. In many LMICs, none of these interventions are reliably available.
The ISN’s 0by25 Initiative — launched to eliminate preventable AKI deaths by 2025 and described in a landmark 2015 publication in Kidney International by Mehta and colleagues — galvanized global attention to this issue. The initiative demonstrated that most AKI deaths in LMICs are preventable through basic measures: early clinical recognition, fluid resuscitation, infection management, and avoidance of nephrotoxic agents. The ISN worked with partners across multiple countries to develop the AKI toolkit — practical protocols designed specifically for resource-limited healthcare settings.
Common Preventable Causes of AKI Mortality in LMICs
- Severe diarrheal illness and dehydration leading to pre-renal acute kidney injury
- Obstetric complications including septic abortion, eclampsia, and postpartum hemorrhage
- Sepsis from endemic infections such as malaria, typhoid, and leptospirosis
- Snake envenomation, which causes direct nephrotoxicity in tropical regions
- Nephrotoxic traditional remedies and unregulated herbal medicines
- Delayed hospital presentation due to limited access to emergency care
Treatment Gaps and the Human Cost of End-Stage Renal Disease
Without kidney replacement therapy, ESRD is uniformly fatal within weeks to months. In high-income countries, dialysis access is treated as a medical right, supported by universal health coverage or insurance systems. In much of sub-Saharan Africa, South Asia, Latin America, and Oceania, the reality is starkly different. Hemodialysis requires specialized machines, treated water, consumables, and trained staff — it is often confined to major urban centers with out-of-pocket costs that exceed the annual income of most patients. Peritoneal dialysis, potentially more cost-effective and home-based, remains underdeveloped in most low-income nations due to supply chain gaps and insufficient training.
Kidney transplantation — the most effective long-term treatment for ESRD — is available in only a minority of LMIC nations, and where programs exist, they are constrained by limited surgical capacity, inadequate immunosuppression availability, and absent deceased-donor organ donation systems. The result is that the vast majority of ESRD patients in the poorest countries die without ever receiving kidney replacement therapy.
| Treatment Option | Effectiveness | Cost in LMICs | Availability in LMICs | Key Barriers |
|---|---|---|---|---|
| Hemodialysis | High for ESRD | Very high relative to income | Urban centers only | Cost, infrastructure, power supply |
| Peritoneal Dialysis | Comparable to HD | Potentially lower | Limited | Supply chains, training, sterility |
| Kidney Transplantation | Highest (long-term) | Requires donor + surgery | Rare | Donor availability, immunosuppression cost |
| Conservative Management | Palliative only | Low | Variable | Lack of palliative care frameworks |
| CKD Prevention & Early Rx | High (pre-ESRD) | Low to moderate | Improving | Screening access, specialist shortage |
The Role of International Coordination and Health Equity Principles
Addressing CKD in LMICs is not merely a clinical challenge — it is a matter of global health equity. The ISN (International Society of Nephrology) has consistently framed kidney disease as a systemic failure requiring coordinated responses at national, regional, and international levels. Health equity in this context means that a person’s likelihood of developing CKD, receiving a timely diagnosis, and accessing effective treatment should not be determined by their country of birth or income level. Currently, these factors are profoundly influential — and the kidney care gap between high-income and low-income countries is among the widest of any major non-communicable disease.
The International Society of Nephrology continues to play a catalytic role through its educational programs, sister society partnerships, regional advocacy, and support for clinical capacity building in under-resourced communities. The ISN’s commitment to global kidney health is grounded in the conviction that evidence-based medicine and health equity are not competing values — they are mutually reinforcing foundations for a more just and effective global health system.
Priority Actions for Closing the Global Kidney Care Gap
- Strengthen primary care systems to enable early detection and management of hypertension and diabetes
- Integrate CKD screening into existing non-communicable disease programs at the national level
- Expand nephrology workforce training and task-sharing with community health workers
- Increase international development funding for kidney health infrastructure in LMICs
- Advocate for affordable access to kidney replacement therapies through health system financing
- Support national CKD policy development guided by GKHA data and ISN technical expertise
- Promote regional partnerships between nephrology societies to share capacity and knowledge
The International Society of Nephrology continues to play a catalytic role in this space through its educational programs, sister society partnerships, regional advocacy, and direct support for clinical capacity building in under-resourced nephrology communities. The ISN’s commitment to advancing kidney health globally is grounded in the conviction that evidence-based medicine and health equity principles are not competing values — they are mutually reinforcing foundations for a more just and effective global health system.
Emerging Strategies and Reasons for Cautious Optimism
Despite the scale of the challenge, several converging trends offer reasons for cautious optimism. Point-of-care diagnostic technologies — low-cost urine dipstick tests, portable blood pressure monitors, and handheld creatinine analyzers — are making early CKD detection feasible even without formal laboratory infrastructure. Digital health platforms and telemedicine are beginning to extend nephrology specialist expertise to rural populations that would otherwise have no access to kidney care.
In the pharmaceutical domain, sodium-glucose cotransporter-2 (SGLT2) inhibitors have demonstrated substantial kidney-protective effects across a broad range of