Chronic kidney disease

Health burden of kidney disease recognized by UN

Non-communicable diseases (NCDs) are taking center stage in global health policy. Intensive lobbying by the International Society of Nephrology has gained recognition for chronic kidney disease (CKD) as a major NCD. Continuing advocacy is needed for the health risk of CKD to be understood and opportunities for prevention and treatment grasped.

“...UN member states can no longer choose to invest little energy in public health strategies...”

On September 19–20 2011 in New York, USA, the United Nations (UN) held a high-level meeting to address the prevention and control of non-communicable diseases (NCDs). That the UN should choose this theme for a high-level meeting illustrates the steady growth in awareness of the global importance of NCDs. The WHO, for instance, has increasingly emphasized the health burden of NCDs, especially in developing countries, where previously the health risks of communicable diseases were seen as paramount. UN high-level meetings are meetings of the General Assembly of member states, and Political Declarations, which are the product of such meetings, should in turn mandate member states to take action.

When the high-level meeting on the prevention and control of NCDs was first announced, joy within the health community that NCDs were at last being given proper high-level exposure soon gave way to energetic lobbying as organizations that represent particular NCDs or components of NCDs jockeyed to ensure that 'their' disease received due priority. However, the UN and WHO soon made clear that both the meeting and the Political Declaration would only explicitly discuss four major NCD areas—cardiovascular diseases, cancer, chronic respiratory diseases and diabetes—considered by the WHO to be the major NCD killers. Organizations that advocate for these diseases soon formed themselves into an 'NCD Alliance' and did not invite groups that represented other NCDs into the alliance except in a subsidiary role. Despite intensive lobbying from many directions, the draft Political Declaration contained no mention of any other specific disease area until up to a few weeks before the high-level meeting.

The International Society of Nephrology (ISN) began in mid-2011 to advocate energetically to redress this imbalance to ensure that chronic kidney disease (CKD) was given due importance as a major NCD that has a profound negative effect on health in its own right, as well as being a multiplier of cardiovascular risk in other diseases.1 By contrast, the stance of the WHO has been that CKD is only important as a consequence of cardiovascular diseases (including hypertension) and diabetes, so that a proper focus on cardiovascular disease and diabetes within the high-level meeting would ensure that CKD was both adequately considered and properly dealt with. The ISN organized a vigorous campaign to correct these misunderstandings and secure a proper position for CKD within the draft Declaration. To ensure that the scientific basis for the importance of CKD was properly understood, a comprehensive review of the clinical and epidemiological evidence supporting CKD as a major NCD was performed.1 The ISN also used its global networks to advocate with health ministers worldwide for the recognition of CKD as a separate entity. The success of this lobbying was manifest through the explicit support for the inclusion of CKD within the Political Declaration; this support was communicated to the WHO ahead of the high-level meeting by a number of health ministers, including those of China, Ethiopia, India, Mexico, Taiwan, Turkey and the USA. When the final Political Declaration was released,2 it was heartening to see the paragraph which stated that the member states of the UN General Assembly “recognize that renal, oral and eye diseases pose a major health burden for many countries and that these diseases share common risk factors and can benefit from common responses to non-communicable diseases”. This acknowledgment was a small but symbolically important step forward; the first time kidney disease has been mentioned as important in its own right in any global health policy statement.

A major focus of the Political Declaration is on introducing lifestyle changes to reduce NCD risk, including tobacco and alcohol control, improving diet, increasing physical activity and reducing poverty, all of which are welcome initiatives as they will have beneficial effects on CKD. To the considerable disappointment of NCD advocacy groups such as the ISN, however, the Political Declaration imposes few firm targets or timelines on the need for member states to embed policies in their public health programs to address these issues. For example, the Declaration merely talks about preparing “recommendations for a set of voluntary global targets for the prevention and control of non-communicable diseases” and mentions that member states are required to “consider the development of national targets and indicators ... to assess the progress made in the prevention and control of non-communicable diseases”. Furthermore, it is not until 2014 that it is proposed that the UN undertake a “comprehensive review ... of the progress achieved”. It therefore remains to be seen whether the Political Declaration will facilitate the much anticipated sea change in global health policy, as there is little to suggest that member states that fail to take effective steps to prevent and control NCDs will incur political opprobrium or any other meaningful penalty. Nonetheless, the meeting and Declaration have undoubtedly opened up a world in which UN member states can no longer choose to invest little energy in public health strategies to reverse the accelerating tide of NCDs—a tide that is advancing even more quickly in the developing world. Those individuals who have the opportunity to advocate with health ministers and other individuals who drive national health policy now have a mandate as never before to promote the importance of CKD in the new NCD policy arena. The importance of CKD as a multiplier of cardiovascular risk is undoubted, but a serious risk remains that policy makers will assume that CKD can entirely be subsumed within the cardiovascular diseases envelope, and that pursuing public health strategies for the prevention, detection and early treatment of diabetes and cardiovascular disease will absolve their responsibilities for separately addressing kidney disease. It is critical that this advocacy highlights the strength of the scientific data supporting the contribution of kidney disease to the burden of NCDs.1 To assist in this regard, the ISN has also published an easily accessible summary of the global impact of kidney disease to share with policy makers.3 The near unsustainable cost of renal replacement therapy even in the developed world, and the well-established efficacy of low-cost interventions to detect and treat CKD early in its course, make a potent public health message for all nephrologists to take forward.

References

  1. 1

    Couser, W. G., Remuzzi, G., Mendis, S. & Tonelli, M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int. http://dx.doi.org/10.1038/ki.2011.368.

  2. 2

    The UN General Assembly. Political declaration of the high-level meeting of the General Assembly on the prevention and control of non-communicable diseases [online], (2011).

  3. 3

    The International Society of Nephrology. A briefing on the global impact of kidney disease [online], (2011).

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J. Feehally is the President of the International Society of Nephrology.

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Feehally, J. Health burden of kidney disease recognized by UN. Nat Rev Nephrol 8, 12–13 (2012). https://doi.org/10.1038/nrneph.2011.191

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